Used by the pensioner to notify L&I of a new mailing address. L&I must receive this form by the first day of the month so your monthly payment is received in a timely manner.

Used by a spouse or children to apply for pension survivor benefits if a total permanent disabled worker dies.

Used by a spouse or children to apply for pension survivor benefits if a total permanent disabled worker dies.

Used by pensioner to authorize L&I to deposit the pension payment to any designated financial institution.

Used by dependents of a deceased worker to file a claim for benefits.

Used by surviving spouse or children of a deceased worker to file a claim for benefits.

Used by surviving spouse or children of a deceased worker to file a claim for benefits.

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.

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.

Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

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.

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.

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.

Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

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.

Used by the pensioner to learn about direct deposit. It accompanies the Authorization for Deposit of Payments- Spanish (F242-174-909) form.

Used by the pensioner to learn about direct deposit. It accompanies the Authorization for Deposit of Payments (F242-174-000) form.

Use by a full-time student who is entitled to receive pension benefits. The student must be at least 18 years old and no older than 23 years old. This form is to prove the students intention to register in an accredited school during the next quarter/semester.

Used by an injured worker who receives an order that states he or she is totally permanently disabled. This questionnaire must be completed in full and all necessary documents attached before his or her pension benefit options can be calculated.

Used by an injured worker who receives an order that states he or she is totally permanently disabled. This questionnaire must be completed in full and all necessary documents attached before his or her pension benefit options can be calculated.

Used by dependents of a deceased worker to file a claim for benefits.

Used by the pensioner to notify L&I of a new mailing address. L&I must receive this form by the first day of the month so your monthly payment is received in a timely manner.

Used by the student and a school official each quarter to verify school enrollment.