Declaración De Derechos Para Viuda(O) Bajo El Programa De Compensación Y Beneficios Para Trabajadores

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Title   Declaración De Derechos Para Viuda(O) Bajo El Programa De Compensación Y Beneficios Para Trabajadores (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 F242-173-911
Availability
Online only. See document above to download.
Keywords claim information, claims, coverage, deceased worker, declaration, disability pension benefits, disabled, entitlement, industrial insurance, occupational death, pension disability benefits, social security offset, sso, surviving spouse, survivor benefits, survivors, worker, worker's compensation, workers compensation, workers' compensation
Languages Spanish , English
Valid dates 11-2009
Contact information
Web pages Workers' Comp Claims

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