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Insurer must complete the following. Due to the employee's death, workers' compensation wage-loss benefits were discontinued on. (date). 1.This form is only available as a downloadable PDF which will be made available to you after you complete your purchase. Minimize the risk of using outdated forms and eliminate rejected fillings. TDI Form NumberDescriptionFile FormatLanguageDWC003Employer's wage statement. Rev. A right of action survives in a case based on a compensable injury that results in the employee's death. Acts 1993, 73rd Leg. OWCP's Division of Coal Mine Workers' Compensation has made a variety of forms available online. These forms are only available in PDF format. Continuation of pay for disability resulting from traumatic, job-related injury, not to exceed 45 calendar days.