Washington > Workers Comp > Claims
Claim For Pension By Spouse Or Children F242-056-000 - Washington
| Claim For Pension By Spouse Or Children Form. This is a Washington form and can be used in Claims Workers Comp . |
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Department of Labor and Industries Division of Insurance Services PO Box 44282 Olympia WA 98504-4282 CLAIM FOR PENSION BY SPOUSE, REGISTERED DOMESTIC PARTNER OR CHILDREN Claim No. Social Security No. of deceased For Prompt Service, All Questions Must be Answered Deceased Worker Name of deceased worker Date of marriage or registered domestic partnership Autopsy? Date of injury Date of birth Date of death Physician treating deceased at time of death Location of death (work, home, hospital, incarcerated) Cause of death Yes Funeral home Address City No Employer when injured Address State ZIP+4 City State ZIP+4 Spouse or Registered Domestic Partner of Deceased Worker Name of spouse or registered domestic partner Residence address Mailing address If separated, give date of separation Cause of separation City City Date of birth Telephone State State ZIP+4 ZIP+4 Social Security No. (ID only) Date of divorce or legal dissolution from deceased Date of remarriage or new registered domestic partnership since worker's death Dependent Children or Stepchildren of the Deceased Name (first, last) Date of birth Sex Name of guardian Address City Telephone Guardian Social Security No. (ID only) State Date of appointment ZIP Date of birth Please attach a copy of the following documents that apply. A. Death certificate. B. Marriage certificate or Declaration of Registered Domestic Partnership C. Birth certificate(s) of child(ren). Are any of the children between the ages of 18 and 23 in a D. Letters of guardianship or custody order. state institution or enrolled full time in school? E. Custody papers for stepchildren. F. Proof of full time enrollment in accredited school of child(ren) If `Yes', please submit proof Yes No between ages 18 and 23. Persons making false statements in obtaining Industrial Insurance benefits are subject to civil and/or criminal penalties under the law. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Today's date Signature of Spouse, Registered Domestic Partner or Guardian X F242-056-000 claim for pension by spouse or children English DP 11-09 American LegalNet, Inc. www.FormsWorkFlow.com
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