Claim For Pension By Dependents {F242-062-000}

Department of Labor and Industries Division of Insurance Services PO Box 44282 Olympia WA 98504-4282 ALL QUESTIONS MUST BE ANSWERED CLAIM FOR PENSION BY DEPENDENTS Claim #. Social Security number of deceased Deceased Worker Name of deceased worker Date of injury Autopsy? Check one Yes Date of death No Date of birth Location where death occurred Physician at time of death Cause of death Employer when injured Address State ZIP+4 If spouse died, give date Funeral Home/Mortuary Address City Was worker ever married? City If worker was divorced, give date State ZIP+4 Date of marriage If worker was separated, give date Yes No Where are spouse or children now? Did worker have spouse or children under 18 years of age? Yes No Person(s) claiming dependency (Both father and mother must join in claim and give necessary details.) Name (last, first, middle) Resident address of dependent Mailing address of dependent Name (last, first, middle) Resident address of dependent Mailing address of dependent Relationship to deceased worker 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? $ Give details on amounts of income from each source City City City City Date of birth State State Date of birth State State Telephone ZIP+4 ZIP+4 Telephone ZIP+4 Zip+4 Are there any other dependents? Yes No What properties do you own? What was your income for the past year from all sources? $ Are you a citizen of the U.S.? If "No", in which country do you have citizenship papers? Continued on next page Yes No (Proof of citizenship will be required if you reside out of the country) F242-062-000 claim for pension by dependents 10-01 American LegalNet, Inc. www.USCourtForms.com Have you worked during the past year? Yes No Amount 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 How much? $ $ $ $ $ $ $ Did you reside with the deceased during the year prior to their death? $ $ $ $ $ $ $ If "No", what amount did you pay for board and lodging? Yes No Part time $ 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 ZIP+4 Date of appointment 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 MY COMMISSION EXPIRES All above statements are true and no facts have been concealed. Today's date Signature of guardian Today's date Signature of dependent F242-062-000 claim for pension by dependents 10-01 American LegalNet, Inc. www.USCourtForms.com