Beneficiary Application for Claim Benefits Form Instructions

Submit the completed Beneficiary Application for Claim Benefits Form to the Division of Insurance Services, Department of Labor and Industries. You can submit it via mail to PO Box 44282, Olympia WA 98504-4282, or fax it to the provided number on the form. Ensure all required fields are filled accurately and all necessary documents are attached. My advice is to double-check the form for completeness and accuracy before submission to avoid delays.

There are no specific important dates for this form in 2024 and 2025.

The purpose of the Beneficiary Application for Claim Benefits form is to facilitate the application process for claim benefits by individuals who are entitled to beneficiary benefits after the death of a worker. It ensures that all necessary information about the deceased worker, the applicant, and any dependent children or stepchildren is collected. Proper submission of this form, along with the required documents, allows the Department of Labor and Industries to process the claim benefits accurately and efficiently.

• 1. Language preference: The preferred language of the applicant.
• 2. Claim Number: Unique number identifying the claim.
• 3. Name of Deceased Worker: Full name of the deceased worker.
• 4. Date of Birth: Date of birth of the deceased worker.
• 5. Location of Death: Place where the worker passed away.
• 6. Autopsy: Indicates if an autopsy was performed.
• 7. Funeral Home Name: Name of the funeral home handling arrangements.
• 8. Funeral Home Address: Address of the funeral home.
• 9. Name of Applicant: Name of the person applying for benefits.
• 10. Residence Address: Applicant's residence address.
• 11. Mailing Address: Applicant's mailing address.
• 12. Social Security Number of Deceased Worker: SSN of the deceased worker.
• 13. Healthcare Provider Treating Deceased at Time of Death: Name of the deceased's healthcare provider at the time of death.
• 14. Date of Injury: Date when the injury occurred.
• 15. Date of Death: Date when the worker passed away.
• 16. Date of Marriage or Registered Domestic Partnership: Date of marriage or domestic partnership registration.
• 17. Cause of Death: Reason for the worker's death.
• 18. Employer When Injured: Employer when the injury occurred.
• 19. Employer When Injured Address: Address of the employer when injured.
• 20. Applicant Information: Details about the applicant.
• 21. Relationship to Deceased: Applicant's relationship to the deceased.
• 22. Date of Birth (Applicant): Applicant's date of birth.
• 23. Telephone Number: Applicant's telephone number.
• 24. If you are a spouse or Registered Domestic Partner, were you living at separate addresses on the date of death?: Answer yes or no and provide the date and cause of separation if applicable.
• 25. Social Security Number (Applicant): Applicant's social security number.
• 26. Date of Divorce or Legal Dissolution from Deceased: Date of divorce or legal dissolution from the deceased.
• 27. Date of Remarriage or New Registered Domestic Partnership since Worker's Death: Date of remarriage or new registered domestic partnership since the worker's death.
• 28. Dependent Children or Stepchildren of Deceased: Information about any dependent children or stepchildren.
• 29. Name (First, Last): Children or stepchildren's full name.
• 30. Date of Birth (Children): Children or stepchildren's date of birth.
• 31. Sex: Gender of children or stepchildren.
• 32. Name of Guardian: Guardian's full name.
• 33. Guardian Social Security No.: Guardian's social security number.
• 34. Address (Guardian): Guardian's address.
• 35. Telephone Number (Guardian): Guardian's telephone number.
• 36. Date of Appointment (Guardian): Date when the guardian was appointed.
• 37. Death certificate and autopsy: Attach death certificate and autopsy report if performed.
• 38. Marriage certificate or Declaration of Registered Domestic Partnership: Attach marriage certificate or declaration.
• 39. Birth certificate(s): Attach birth certificates of children.
• 40. Letters of guardianship or custody order: Attach letters or custody order.
• 41. Custody papers for stepchildren: Attach custody papers for stepchildren.
• 42. Proof of full-time enrollment in accredited school: Attach proof of full-time enrollment for children between ages 18 and 23 in an accredited school.

Failure to submit this form can result in delays or denial of claim benefits.

• Delayed Benefits: Your benefits may be delayed if the form is not submitted on time.
• Denied Claims: Claims may be denied if necessary information or documents are missing.
• Incomplete Application: Incomplete applications will not be processed until all required fields and documents are provided.

• 1. Death of Worker: When a worker has passed away and beneficiaries need to apply for claim benefits.
• 2. Dependent Children: To apply for claim benefits for dependent children or stepchildren.
• 3. Registered Domestic Partnership: When a registered domestic partner needs to apply for claim benefits.
• 4. Legal Guardianship: When a legal guardian of children of the deceased worker needs to apply for benefits.
• 5. Employer Handling: When employers need to handle claim benefits for deceased workers' families.