Free F242-393-000 Pension Benefits Questionnaire - Washington


File Size: 137.8 kB
Pages: 1
Date: October 22, 2008
File Format: PDF
State: Washington
Category: Workers Compensation
Author: Forms Management
Word Count: 556 Words, 3,393 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.lni.wa.gov/forms/pdf/242393af.pdf

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Department of Labor and Industries Pension Benefits Section PO Box 44281 Olympia WA 98504-4281

PENSION BENEFITS QUESTIONNAIRE

You are entitled to receive pension benefits under the Washington Industrial Insurance Act, Title 51, RCW. This information is required by law and necessary for the department to accurately compute your benefits. Please answer the following questions and sign the declaration at the bottom of the page. If you have any questions, you may contact the Pension Benefits Section at (360) 902-5119. Thank you for your assistance. 1.) Submit copies, not originals, of the requested information. Please write your claim number on each document. 2.) Complete, sign and return this form as soon as possible.
Name (Last, First, MI) Mailing address (Provide if no Legal Representative) Residence address (If different than mailing address) Mailing address of Legal Representative (if applicable) Date of birth Phone number Claim Number Social Security number (ID only)

Were you married at the time of your injury or occupational disease? YES NO If yes, please provide a copy of your marriage certificate. (This is required regardless of your current marital status; proof is needed if you were married on the date of injury.) What is your current marital status? Please check the appropriate box. I am married. Name of spouse _________________________ Spouse's date of birth ________________ Provide a copy of your marriage certificate. I have never been married, or I was divorced or widowed before the date of injury. I was divorced on (date of divorce) ___________________. Provide a copy of the signed final decree if the date of divorce is after the date of your injury, as well as a copy of your marriage certificate. I am widowed. Provide a copy of your deceased spouse's death certificate if widowed after the date of injury, as well as a copy of your marriage certificate. What is the current status of your child/children? Please check the appropriate box and provide a copy of each child's birth certificate. I have a child/children less than 18 years of age, or any age if disabled and dependent on me. Medical documentation is required for those who are disabled and dependent on you. I have a child/children who resides with me and I am not currently married to the other parent listed on the birth certificate(s). Provide a copy of the documentation indicating who has legal custody. I have a child/children who resides in another household. Provide a copy of the documentation indicating who has legal custody and give the current name and address of that person. Name of legal custodian Address of legal custodian

I have a child/children between the ages of 18 and 23, who is in an accredited school as a full-time student. Provide written verification of this from the school; provide the student's current address, and a copy of their birth certificate. Have you applied for, or are you receiving benefits from Social Security? YES NO

I understand that the Department of Labor and Industries will use and rely upon my answers to the questions listed above to calculate the amount of my pension under the Washington Industrial Insurance Act, Title 51 RCW. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Signature Date Printed Name

F242-393-000 pension benefits questionnaire 10-2008