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

Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance - (Forms/Publications)
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Title Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance (A fillable form - 129 KB PDF)
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.
Detail
Form number F242-173-333
Availability
Online only. See document above to download.
Keywords claim information, claims, coverage, declaration, dependents, disability benefits, disability pension benefits, disabled, entitlement, espanol, insurance, occupational death, offset, pension disability benefits, social security offset, spanish, sso, surviving children, surviving spouse, survivor benefits, survivors, worker's compensation, workers compensation, workers' compensation
Languages English , Spanish
Valid dates 10-2008
Contact information Managing Injured Workers' Claims
Claims for Job Injuries
Web pages Workers' Comp Claims

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