Declaración de Derechos para Viuda(o) bajo el Programa de Compensación y Beneficios para Trabajadores


Document Information
  Get help downloading & printing files.   How to complete a fillable form.
Title Declaración de Derechos para Viuda(o) bajo el Programa de Compensación y Beneficios para Trabajadores
Description

Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits.

Document number F242-173-911
How to get this document
Keywords claim information, claims, coverage, deceased worker, declaration, disability pension benefits, disabled, entitlement, industrial insurance, occupational death, pension disability benefits, social security offset, sso, surviving spouse, survivor benefits, survivors, worker, worker's compensation, workers compensation, workers' compensation
Alt Language(s) English
Valid dates 11/2009
Contact information
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.