Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance


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Title Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance
Description 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.
Document number F242-173-111
How to get this document
Alt Language(s) Español
Valid dates 11/2009
Contact information
Websites Workers' Comp Claims

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