Address Change Request
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Address Change Request Form. This is a Washington form and can be use in Claims Workers Comp.
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Tags: Address Change Request, F242-107-000, Washington Workers Comp, Claims
Labor and Industries
Pension Benefits Section
PO Box 44281
Olympia WA 98504-4281
ADDRESS CHANGE
REQUEST
(360) 902-5119
Effective Date
NAME
Claim #
Folio #
Please check one:
Pensioner
Widow/er
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 no later than the 8th of
the month to effect payments scheduled to be mailed to you on the 15th of the month. (This does
not effect those who have direct deposit.) Should you choose, for quick arrival, you may fax your
request back to the department at (360) 902-6455.
F242-107-000 address change request 06-2007
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