Declaración de Derechos para Dependiente del Trabajador Fallecido Bajo el Programa de Compensación y Beneficios para Trabajadores

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Title   Declaración de Derechos para Dependiente del Trabajador Fallecido Bajo el Programa de Compensación y Beneficios para Trabajadores (37 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 F242-173-933
Availability
Online only. See document above to download.
Keywords claim information, claims, coverage, deceased worker, declaration, dependents, disability pension benefits, disabled, entitlement, industrial insurance, occupational death, offset, pension disability benefits, social security offset, sso, surviving children, surviving spouse, survivor benefits, survivors, worker's compensation, workers compensation, workers' compensation
Languages Spanish , English
Valid dates 10-2008
Contact information Managing Injured Workers' Claims
Claims for Job Injuries
Web pages Workers' Comp Claims

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