Get a Form or Publication: occupational death
Your search for "occupational death" returned 10 documents.
See also
| Title | Type | Number |
|---|---|---|
| Claim for Pension By Dependents
Also available in: Spanish Used by dependents of a deceased worker to file a claim for benefits. |
Form | F242-062-000 |
| Claim for Pension by Spouse or Children
Also available in: Spanish Used by a spouse or dependents of a deceased worker. The workers' fatal accident or occupational disease incurred in the course of their employment. This application is needed to determine if applicant(s) is/are entitled to a survivor benefit. |
Form | F242-056-000 |
| Claim for Pension by Spouse or Children - Spanish Reclamo para Pensión de Esposo(a) o Los Niños
Also available in: English Used by a spouse or dependents of a deceased worker. The workers' fatal accident or occupational disease incurred in the course of their employment. This application is needed to determine if applicant(s) is/are entitled to a survivor benefit. |
Form | F242-056-999 |
| Declaración De Derechos Para Dependiente Del Trabajador Fallecido Bajo El Programa De Compensación Y Beneficios Para Trabajadores
Also available in: English 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. |
Form | F242-173-933 |
| Declaración De Derechos Para Padres O Tutor Bajo El Programa De Compensación Y Beneficios Para Trabajadores
Also available in: English Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody. |
Form | F242-173-922 |
| Declaración De Derechos Para Viuda(O) Bajo El Programa De Compensación Y Beneficios Para Trabajadores
Also available in: English 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. |
Form | F242-173-911 |
| Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance
Also available in: Spanish 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. |
Form | F242-173-333 |
| Declaration of Entitlement for Guardian Benefits under Industrial Insurance
Also available in: Spanish Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody. |
Form | F242-173-222 |
| Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance
Also available in: Spanish 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. |
Form | F242-173-111 |
| Reclamo for Pensión por Dependientes
Also available in: English Used by dependents of a deceased worker to file a claim for benefits. |
Form | F242-062-999 |
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