Department of Labor and Industries Division of Insurance Services PO Box 44282 Olympia WA 98504-4282 CLAIM FOR PENSION BY DEPENDENTS Claim #. ALL QUESTIONS MUST BE ANSWERED Social Security number of deceased Deceased Worker Name of deceased worker Date of injury Autopsy? Check one Date of birth Date of death Yes No Physician at time of death Location where death occurred Cause of death Funeral Home/Mortuary Employer when injured Address Address City State Was worker ever married? Yes Date of marriage ZIP+4 City If spouse died, give date State If worker was divorced, give date ZIP+4 If worker was separated, give date No Did worker have spouse or children under 18 years of age? Yes No Where are spouse or children now? Person(s) claiming dependency (Both father and mother must join in claim and give necessary details.) Name (last, first, middle) Date of birth Telephone Resident address of dependent City State ZIP+4 Mailing address of dependent City State ZIP+4 Name (last, first, middle) Date of birth Telephone Resident address of dependent City State ZIP+4 Mailing address of dependent City State Zip+4 Relationship to deceased worker Are there any other dependents? Yes No Who are the other dependents? Dependents must answer all When did you commence to be dependent? of the following questions: What incapacity (physical/mental/sensory) makes you dependent? Have your attending physician give a statement in writing as to your condition and attach it to this claim. What is your indebtedness? $ What properties do you own? What was your income for the past year from all sources? $ Are you a citizen of the U.S.? Yes Give details on amounts of income from each source If “No”, in which country do you have citizenship papers? No (Proof of citizenship will be required if you reside out of the country) Continued on next page F242-062-000 claim for pension by dependents 10-01 American LegalNet, Inc. www.USCourtForms.com Wages when working $ per State very specifically the amounts contributed by the deceased to you during one year prior to their death. Date How paid Amount Date How paid Have you worked during the past year? Yes No Amount How much? $ $ $ $ $ $ $ $ $ $ $ $ $ $ Did you reside with the deceased during the year prior to their death? Yes No Part time If “No”, what amount did you pay for board and lodging? $ What other persons or agencies contribute to your support? Guardian (If dependents are incompetent, claim must be made through a guardian with proper documents attached.) Name of guardian Address Telephone# State Date of appointment ZIP+4 Date of birth Is guardian acting at this time? Yes No Documents to be attached: A. Copy of Death Certificate. B. Copy of Birth Ceretificate of Applicant. C. Guardian must send copy of Letters of Guardianship or Custody Order. D. Receipts, check copies, bank certificates, letters or other documents showing that you received the sums you have set forth above. E. Certificate from the family physician showing your physical/mental/sensory inability to make a living and thus show your dependency. Other Instructions: Claimants are advised that, upon receipt of this claim, the department, if it has not already done so, will write for and procure, the report of death from the attending physician or coroner or an undertaker and such other proofs as may be required, whereupon this claim will be decided. Give all other facts that you think may assist the department in determining your claim: SUBSCRIBED AND SWORN TO BEFORE ME THIS DATE NOTARY PUBLIC RESIDING AT All above statements are true and no facts have been concealed. Today’s date Signature of guardian MY COMMISSION EXPIRES Today’s date F242-062-000 claim for pension by dependents 10-01 Signature of dependent American LegalNet, Inc. www.USCourtForms.com