Department of Labor and Industries Division of Insurance Services PO Box 44282 Olympia WA 98504-4282 Language preference (check one): English Spanish Russian Korean Chinese Vietnamese Laotian Beneficiary Application for Claim Benefits Cambodian Other: Deceased Worker Claim Number Name of Deceased Worker Date of Birth Location of Death Autopsy Cause of Death Date of Injury Social Security Number of Deceased Worker Healthcare Provider Treating Deceased at Time of Death Date of Death Date of Marriage or Registered Domestic Partnership Yes No Employer When Injured Employer When Injured Address State Zip Code + 4 City State Zip Code + 4 Funeral Home Name Funeral Home Address City Applicant Information Name of Applicant Residence Address Mailing Address Relationship to Deceased City City Date of Birth State State Telephone Number Zip Code + 4 Zip Code + 4 If you are a spouse or Registered Domestic Partner, were you living at separate addresses on the date of death? No Yes If yes, give the date and cause of separation below. Cause of Separation Date of Divorce or Legal Dissolution from Deceased Date of Remarriage or New Registered Domestic Partnership since Worker's Death Date of Separation Social Security Number Dependent Children or Stepchildren of Deceased Name (First, Last) Date of Birth Sex Guardian Name of Guardian Address City Telephone Number State Date of Appointment Zip Code +4 Date of Birth Social Security No. (ID only) Are any of the children between the ages of 18 and 23 in a state institution or enrolled full time in school? Please attach a copy of the following documents that apply: A. Death certificate and autopsy if performed. B. Marriage certificate or Declaration of Registered Domestic Partnership. C. Birth certificate(s) of children D. Letters of guardianship or custody order. E. Custody papers for stepchildren. F. Proof of full time enrollment in accredited school of children between ages 18 and 23. No Yes If yes, please submit proof. 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. Applicant's Signature Date X F242-056-000 Beneficiary Application for Claim Benefits 07-2016 American LegalNet, Inc. www.FormsWorkFlow.com