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
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.

Document number F242-173-933
How to get this document
Keywords claim information, claims, coverage, deceased worker, declaration, dependents, disability pension benefits, disabled, entitlement, industrial insurance, occupational death, offset, pension disability benefits, social security offset, sso, surviving children, surviving spouse, survivor benefits, survivors, worker's compensation, workers compensation, workers' compensation
Alt Language(s) English
Valid dates 10/2008
Contact information Claims for Job Injuries, Employer Services
Websites Workers' Comp Claims

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