Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance

Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance - (Forms/Publications)
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Title Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance (A fillable form - 127 KB PDF)
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.
Detail
Form number F242-173-111
Availability
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Keywords claim information, claims, coverage, deceased worker, disability pension benefits, disabled, espanol, occupational death, offset, pension disability benefits, social security offset, spanish, sso, surviving spouse, survivor benefits, survivors, worker, worker's compensation, workers compensation, workers' compensation
Languages English , Spanish
Valid dates 11-2009
Contact information
Web pages Workers' Comp Claims

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