Obtenga un formulario o publicación: entitlement

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Título	Tipo	Número
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 Trabajador Totalmente Discapacitado Bajo El Programa De Compensación Y Beneficios Para Trabajadores Also available in: English 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.	Form	F242-173-944
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 Totally Disabled Worker Benefits Under Industrial Insurance Also available in: Spanish 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.	Form	F242-173-444
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
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