Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance


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Title Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance
Description Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.
Document number F242-173-444
How to get this document
Alt Language(s) Español
Valid dates 11/2009
Contact information
Websites Workers' Comp Claims

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