Declaration of Entitlement for Guardian Benefits under Industrial Insurance

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Title Declaration of Entitlement for Guardian Benefits under Industrial Insurance (A fillable form - 133 KB PDF)
Description Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody.
Detail
Form number F242-173-222
Availability
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Keywords claim information, claims, coverage, disability pension benefits, espanol, occupational death, pension disability benefits, social security offset, spanish, sso, surviving children, survivor benefits, survivors, 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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