Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance


Document Information
  Get help downloading & printing files.   How to complete a fillable form.
Title Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance
Description Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.
Document number F242-173-333
How to get this document
Alt Language(s) Español
Valid dates 10/2008
Contact information Claims for Job Injuries, Employer Services
Websites Workers' Comp Claims

End of main content, page footer follows.

Access Washington official state portal

© Washington State Dept. of Labor & Industries. Use of this site is subject to the laws of the state of Washington.