Address Change Request For Pensioners
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Address Change Request For Pensioners Form. This is a Washington form and can be use in Claims Workers Comp.
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Tags: Address Change Request For Pensioners, F242-107-000, Washington Workers Comp, Claims
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
Claim #
Folio #
Please check one:
Pensioner
Widow/er
Registered Domestic Partner
Dependent
Power of Attorney/Guardian
New Mailing Address
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
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