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
Keywords claim information, claims, coverage, disability pension benefits, espanol, injured worker, injury, insurance, occupational injuries, pension disability benefits, social security offset, spanish, sso, worker's compensation, workers compensation, workers' compensation
Alt Language(s) Español
Valid dates 11/2009
Contact information
Websites Workers' Comp Claims

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