Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance


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Title Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance
Description 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.
Document number F242-173-333
How to get this document
Keywords claim information, claims, coverage, declaration, dependents, disability benefits, disability pension benefits, disabled, entitlement, espanol, insurance, occupational death, offset, pension disability benefits, social security offset, spanish, sso, surviving children, surviving spouse, survivor benefits, survivors, worker's compensation, workers compensation, workers' compensation
Alt Language(s) Español
Valid dates 10/2008
Contact information Claims for Job Injuries, Employer Services
Websites Workers' Comp Claims

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