Free F242-391-000 application for pension benefits by spouse or children - Washington

Department of Labor and Industries Division of Insurance Services PO Box 44281 Olympia WA 98504-4281

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For Prompt Service, All Questions Must be Answered

APPLICATION FOR PENSION BENEFITS BY SPOUSE OR CHILDREN
Claim No. Folio No. Social Security No. of deceased

Deceased Worker
Name of deceased worker Autopsy? Cause of death Date of death Location of death (work, home, hospital, incarcerated) Physician

Yes

No Spouse of Deceased Worker

Name of spouse Residence address Mailing address (if different) Date of marriage Social Security No. (ID only) Continue direct deposit? If separated, give date of separation City City

Date of birth

Telephone no. State State ZIP+4 ZIP+4

Cause of separation If remarried since death of worker, give date of remarriage

If divorced from deceased, give date of divorce If `Yes', please verify name of bank:

No

Yes Guardian
Name of guardian Address City Telephone no. State Date of appointment ZIP Social Security No. (ID only)

Dependent Children or Stepchildren of the Deceased
Name (first, last) Date of birth Sex

Date of birth

Are any of the children between the ages of 18 and 23 in a state institution or enrolled full time in school?

No

Yes

If `Yes', please submit proof

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

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F242-391-000 application for pension benefits by spouse or children ­ English 3-08