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Claim For Pension By Dependents Form. This is a Washington form and can be use in Claims Workers Comp.
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Tags: Claim For Pension By Dependents, F242-062-000, Washington Workers Comp, Claims
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
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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
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