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

Información del documento
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Título

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

(Un formulario electrónico)- 132 KB PDF)
Descripción

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.

Detalle
Número del formulario F242-173-333
Disponibilidad Online only
Palabras claves 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
Idiomas English, Spanish
Fechas válidas 10-2008
Contacto Managing Injured Workers' Claims
Claims for Job Injuries
Páginas de Internet Workers' Comp Claims

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