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Industrial Insurance. For benefits to continue without interruption, this.Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance (F242-422-999). Department of Labor and Industries. For benefits to continue without interruption this Declaration of Entitlement must be completed in full, signed, notarized and returned within 30 days. These are the most frequently requested U.S. Department of Labor forms. You can complete some forms online, while you can download and print all others. Otherwise you can complete the "Coverage Research Service Request" form in your packet and mail it to: Workers' Compensation Insurance Rating Bureau (WCIRB). (b) is caring for a dependent child of the deceased. 4. Workers receive benefits regardless of who was at fault in the accident.