Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance

Información del documento
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Título Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance (Un formulario electrónico)- 127 KB PDF)
Descripción 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.
Detalle
Número del formulario F242-173-111
Disponibilidad solicítelo
Palabras claves claim information, claims, coverage, deceased worker, disability pension benefits, disabled, espanol, occupational death, offset, pension disability benefits, social security offset, spanish, sso, surviving spouse, survivor benefits, survivors, worker, worker's compensation, workers compensation, workers' compensation
Idiomas English, Spanish
Fechas válidas 11-2009
Contacto
Páginas de Internet Workers' Comp Claims

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