Fill and Sign the Settle a Claim Lampampi Washington State Access Washington Form

Department of Labor and Industries Division of Insurance Services PO Box 44282 Olympia WA 98504-4282 Beneficiary Application for Claim Benefits Language preference (check one): English Spanish Russia n Korean Chinese Vietnamese Laotian Cambodian Other: Deceased Worker Claim Number Social Security Number of Deceased Worker Name of Deceased Worker Healthcare Provider Treating Deceased at Time of Death Date of Birth Date of Injury Date of Death Location of Death Date of Marriage or Registered Domestic Partnership Autopsy Yes No Cause of Death Funeral Home Name Employer When Injured Funeral Home Address Employer When Injured Address City State Zip Code + 4 City State Zip Code + 4 Applicant Information Name of Applicant Relationship to Deceased Date of Birth Telephone Number Residence Address City State Zip Code + 4 Mailing Address City State Zip Code + 4 If you are a spouse o r Registered Domestic Partner , were you living at separate addresses on the date of death? No Yes If yes, give the date and cause of separation below. Date of Separation Cause of Separation Social Security Number Date of Divorce or Legal Dissolution from Deceased Date of Remarriage or New Registered Domestic Partnership since Worker’s Death Dependent Children or Stepchildren of Deceased Guardian Name (First, Last) Date of Birth Sex Name of Guardian Social Security No. (ID only) Address City State Zip Code +4 Telephone Number Date of Appointment Date of Birth Please attach a copy of the following documents that apply: A. Death certificate and autopsy if performed. B. Marriage certificate or Declaration of Registered Domestic Partnership. C. Birth certificate(s) of children D. Letters of guardianship or custody order. E. Custody papers for stepchildren. F. Proof of full time enrollment in accredited school of children between ages 18 and 23. 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. Persons making false statements in obtaining Industrial Insurance ben efits 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. Applicant’s Signature X Date F242- 056- 000 Beneficiary Application for Claim Benefits 07-2016