Declaración De Derechos Para Dependiente Del Trabajador Fallecido Bajo El Programa De Compensación Y Beneficios Para Trabajadores


Declaración De Derechos Para Dependiente Del Trabajador Fallecido Bajo El Programa De Compensación Y Beneficios Para Trabajadores

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Title	Declaración De Derechos Para Dependiente Del Trabajador Fallecido Bajo El Programa De Compensación Y Beneficios Para Trabajadores (37 KB PDF)
Description	Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.
Detail
Form number	F242-173-933
Availability	Online only
Keywords	benefits, claim information, claims, coverage, deceased, deceased worker, declaration, dependents, disability, disability & pension benefits, disability and pension benefits, disability benefits, disability pension benefits, disabled, entitlement, industrial insurance, insurance, occupation, occupational, occupational death, offset, pension, pension & disability benefits, pension and disability benefits, pension benefits, pension disability benefits, security, social, social security, social security offset, sso, surviving children, surviving spouse, survivor benefits, survivors, worker, worker's compensation, workers compensation, workers' compensation
Languages	Spanish , English
Valid dates	10-2008
Contact information	Managing Injured Workers' Claims Claims for Job Injuries
Web pages	Workers' Comp Claims