Election for Counties and Municipal Corporations. A county or municipal corporation may elect for the death benefits provisions of Labor and Employment Article, §§9-683.1—9-683.5, Annotated Code of Maryland, to apply to its public safety employees subject to the statutory presumption set forth in Labor and Employment Article, §9-503, Annotated Code of Maryland. A county or municipal corporation may make this election by: Completing an online form, available at the Commission's website; and Attaching a copy of the county or municipal corporation's ordinance or resolution making the election. The Commission shall issue a date-stamped notice advising the county or municipal government of its receipt of the election. The date stamp of the Commission's notice will be used as the effective date of the election. All death benefit claims arising out of a death that occurred after the date of election are subject to the death benefits provisions set forth in Labor and Employment Article, §§9-683.1—9-683.5, Annotated Code of Maryland. Dependent Claim for Death Benefits. To initiate a claim for death benefits, a dependent of the deceased employee or an individual authorized to act on behalf of the dependent claimant shall file a dependent death benefits claim form with the Commission. The Commission may reject a claim form that does not contain sufficient information to process the claim including: The dependent claimant's name and, if applicable, the authorized individual's name; The dependent claimant's address and, if applicable, the authorized individual's address; The deceased employee's name; The deceased employee's address; The deceased employee's date of birth; The date of the accident or occupational disease; The member of the deceased employee's body that was injured; A description of how the accidental injury or occupational disease occurred; The deceased employee's date of death; and The deceased employee's employer's name and address. If the information set forth in §B(2) of this regulation is unavailable or does not exist the claimant shall: Enter all zeros (0) in the spaces provided for the information; and Attach a signed statement certifying that the information is unavailable or does not exist. Signature. The dependent claimant or authorized individual shall sign the dependent death benefit claim form. An authorized individual shall submit documentation establishing his or her authority to act on behalf of the dependent claimant with the claim form. Submission of Supporting Documentation. When completing the dependent death benefits claim form, the dependent claimant or authorized individual shall submit: An authorization for disclosure of health information signed by the dependent claimant or authorized individual, directing the deceased employee's health care providers to disclose to the dependent claimant's attorney, the deceased employee's attorney, the deceased employee's employer, the employer's insurer, or any agent thereof, the deceased employee's medical records that are relevant to: The member of the body that was injured by an accident or occupational disease, as indicated on the claim form; and The description of how the accidental injury or occupational disease occurred, as indicated on the claim form; A certification of funeral expenses, if the dependent claimant is making a claim for funeral benefits, which shall: Include the name of the deceased employee; Include an attached itemized statement of the services performed and corresponding costs; Be signed by the provider of the funeral services or undertaker; and Be signed by the person authorizing the burial or other services. A certified copy of the certificate of death for the deceased employee; A certified copy of the certificate of marriage for the dependent claimant and deceased employee, if the dependent claimant is the surviving spouse of the employee; and A certified copy of the certificate of birth for the dependent claimant, if the dependent claimant is the surviving child of the deceased employee. Prior to the scheduled hearing on the death claim, the dependent claimant or authorized individual who filed the claim shall submit: Proof of family income at the date of the accidental personal injury or disablement; An affidavit attesting to the authenticity of the documents submitted as proof of family income; and If applicable, copies of any legal documents or orders directing the deceased employee to pay child support or alimony. Proof of family income may include: Payroll stubs or wage records covering the 14-week period prior to the accidental injury or date of disablement; W-2s; 1099 forms or other evidence of earnings from self-employment; and Tax returns. If the dependent claimant or authorized individual does not have access to proof of income records for some alleged dependent claimants, the dependent claimant or authorized individual shall submit evidence demonstrating the efforts made to obtain these records, including any Commission subpoenas. Revocation of Authorization. A dependent claimant or authorized individual may revoke an authorization for disclosure of health information in writing. The dependent claimant or authorized individual shall serve a copy of the written revocation on all the parties in the case. The Commission shall reject a dependent death benefits claim form that does not contain a signed authorization for disclosure of health information. Date of Filing. A claim is considered filed on the date that a completed and signed claim form, including the signed authorization for disclosure of health information, is received by the Commission. The Commission's date of receipt is determined by the date stamp affixed on the claim form. Electronic Submission. A dependent death benefits claim that is submitted electronically is not considered filed until the signed claim form, including the signed authorization for disclosure of health information, is received by the Commission. The Commission's date of receipt is determined by the date stamp affixed on the claim form. Claim for Funeral Benefits Only. If the deceased employee has no dependents, any person or entity responsible for paying, or who has paid, the deceased employee's funeral expenses may initiate a claim for funeral benefits by filing with the Commission a signed funeral benefits only claim form certifying that the information submitted on the form is accurate. The Commission may reject a funeral benefits only claim form that does not contain sufficient information to process the claim including: The filing party's name and address; The deceased employee's name and address; The deceased employee's employer's name and address; The date of accident or occupational disease; and The deceased employee's date of death. When completing the funeral benefits only claim form the filing party shall attach a certification of funeral expenses, which shall: Include the name of the deceased employee; Include an attached itemized statement of the services performed and corresponding costs; Be signed by the provider of the funeral services or undertaker; and Be signed by the person authorizing the burial or other services.