Death Benefits Trust Claim Application Process

Death Benefits Trust Claim Application Process 1. Death Benefits Trust Claim Application (Form DB-020) must be completed by the chief law enforcement officer or public agency director of the "Employer" when a covered individual is killed while engaged in the performance of the individual's official duties and sent by the Employer to the Mississippi Department of Public Safety along with the original copy of Form DB-010. 2. The following documents must be included with Form DB-020 at the time of submission: a. A certified copy of the original certificate of death; b. If one was completed, the original of the Beneficiary Designation Form (Form DB- 010); c. An attested copy of the incident report documenting how death occurred; and d. An attested copy of the covered employer’s record showing deceased’s date of hire or membership. 3. The submission of Form DB-010 and Form DB-020 does not guarantee payment under MCA §45-2-1. The Mississippi Department of Public Safety makes the final determination of payment under the statute. 4. Submission of the Death Benefits Trust Claim Application should be made by the Employer and filed with the Legal Division of the Mississippi Department of Public Safety at Post Office Box 958 in Jackson, Mississippi 39205. Questions or concerns should be directed to DeathBenefitsTrust@dps.ms.gov. 5. All completed applications for death benefits claims will be presented by the Legal Division and evaluated by the Commissioner and the Executive Committee during the Department’s Executive Staff Meeting.