Washington > Workers Comp > Claims
Address Change Request For Pensioners F242-107-000 - Washington
| Address Change Request For Pensioners Form. This is a Washington form and can be used in Claims Workers Comp . |
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Labor and Industries Pension Benefits Section PO Box 44281 Olympia WA 98504-4281 Phone: (360) 902-5119 FAX: (360) 902-6455 ADDRESS CHANGE REQUEST FOR PENSIONERS THIS FORM IS FOR PENSION RECIPIENTS ONLY NOT FOR INJURED WORKER CLAIMS Effective Date NAME Please check one: Pensioner Widow/er Registered Domestic Partner New Mailing Address Dependent Power of Attorney/Guardian Claim # Folio # City State ZIP+4 Please provide us with the telephone number you would prefer to be contacted at: Work Telephone Number (if applicable) Home Telephone Number Signature Date (PLEASE NOTE that any change of address must be received in this office by the 5th of the month in order for payments to be mailed to a new address. Direct deposit is not affected by address changes if you are keeping the same account. Should you choose, you may fax your request back to the department at (360) 902-6455. F242-107-000 address change request for pensioners 07-2011 American LegalNet, Inc. www.FormsWorkFlow.com
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