Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance
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| Document Information | ||
|---|---|---|
 Get help downloading & printing files.  How to complete a fillable form. |
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| Title |
Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance (A fillable form - 137 KB PDF)
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| 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. | |
| Detail | ||
| Form number | F242-173-444 | |
| Availability | Order it |
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| 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 | |
| Languages | English , Spanish | |
| Valid dates | 11-2009 | |
| Contact information | ||
| Web pages | Workers' Comp Claims | |
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