Department of Labor and Industries Division of Insurance Services PO Box 44282 Olympia WA 98504-4282 CLAIM FOR PENSION BY SPOUSE OR CHILDREN Claim No. For Prompt Service, All Questions Must be Answered Social Security No. of deceased Deceased Worker Name of deceased worker Date of marriage Date of birth Date of injury Physician treating deceased at time of death Date of death Location of death (work, home, hospital, incarcerated) Cause of death Autopsy? Yes No Funeral home Employer when injured Address Address City State ZIP+4 City State ZIP+4 Spouse of Deceased Worker Name of spouse Date of birth Telephone Residence address City State ZIP+4 Mailing address City State ZIP+4 If separated, give date of separation Social Security No. (ID only) Cause of separation If divorced from deceased, give date of divorce Are you a citizen of the U.S.? Yes If remarried since death of worker, give date of remarriage. If ‘No’, in which country do you have citizenship papers? No Dependent Children or Stepchildren of the Deceased Name (first, last) Date of birth Guardian Sex Name of guardian Social Security No. (ID only) Address City Telephone Are any of the children between the ages of 18 and 23 in a state institution or enrolled full time in school? Yes No If ‘Yes’, please submit proof State Date of appointment ZIP Date of birth Please attach the following documents that apply. A. Copy of death certificate. B. Spouse must send copy of marriage certificate. C. Guardian must send copy of letters of guardianship or custody order. D. Copy of birth certificate(s) of child(ren). E. Proof of full time enrollment in accredited school if child(ren) between ages 18 and 23. F. Copy of custody papers for stepchildren. 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. Today’s date Signature of Spouse or Guardian X F242-056-000 claim for pension by spouse or children – English 3-08 American LegalNet, Inc. www.FormsWorkflow.com