CA-722 Notice of Law Enforcement Officer's Death

Notice of Law Enforcement Officer's
Print
Death

U.S. Department of Labor

Reset

Employment
Standards
Administration
Office
of Workers'
Compensation
Programs
Office of Workers' Compensation Programs
OMB
OMB No.
No. 1240-0022
1215-0116
Expires:
Expires: XX-XX-XXXX
08-31-2007

Note: Persons are not required to respond to this collection of information unless it displays a currently
valid OMB control number.
1. Name and Mailing Address Including ZIP Code of
Employing Organization

EMPLOYING ORGANIZATION'S REPORT
2. Name of Deceased Officer's Immediate Superior

3. Name and Telephone Number of Person to Contact

6. Social Security Number

5. Officer's Birth Date
(month, day, year)

4. Last, First, Middle Name of Deceased Officer

7. Officer's Last Mailing Address Including ZIP Code

8. Date and Hour of Injury

Base
Quarters, If Extra
13. On Day of Injury
Officer's Shift

12. List and Show Value of Other Pay Increments on Date
of injury

$
$

Per
Per

$

Per

$

Per

$

Per

a. Began
AM
am/
pm
PM

b. Ended
AM
am/
pm
PM

16. Did Officer Work for the Organization a Full 11
Months Immediately Prior to Injury?
Yes Yes

AM
PM

11. Rate of Pay on Date of Injury

Subsistence, If Extra

10. Date and Hour Pay Stopped

9. Date of Death

AM
am/
PMpm

15. Circle Days Normally
Worked Per Week (exclusive
MOTUTUWE
WETH
TH FR
FR SA
SA
of overtime) SUSUMO

14. Number of Hours
Worked Per Day (exclusive
of overtime)

17. If No, Would His Job Have Afforded Employment
For 11 Months Except For the Injury?

Yes
Yes

No No

No

No

18. Describe Nature of Injury Which Caused Death

19. Describe Fully How the Officer's Death Occurred While Enforcing the Laws of the United States. If possible, give the U.S. Code Citation.

20. Was Officer Performing Regular Duties When Injured? If No, Give Full Explanation

Yes

No

21. Was the Injury Caused By:
a. Officer's Willful Misconduct? YesYes
YesYes
b. Officer's intoxication?

No No
No No

c. Officer's Intent to Bring About Injury to Self or Another (other than normally required in performance of duty)? Yes
Attach Detailed Explanation for Any ''Yes'' Answers

Yes

No

No

22. If Known, Give Name and Address of Suspect(s) or Witness(es) With Whom Officer Was Involved When Injured

23. Has Application Been Made for Compensation, Annuity, or Other Benefits as a Result of This Death Under Any Compensation Law, Police Death
or Survivor's Benefit Fund, or Other Such Fund? Yes Yes
No No
If Yes, Give Name and Address of Organization With Which Application Was Filed.

Page 1 of 6

FormCA-722a
CA-722a
Form
Rev.Oct
Mar2001
2010
Rev.

24. Define, Explain, or Identify the Circumstances of This Injury Resulting in Death Which Involves the
United States (see the first paragraph of the instruction sheet attached to this form).

25. Signature
We hereby certify that the officer, whose death is
reported above, was injured while in performance
of duty under 5 U.S.C. 8101 et seq., as extended
by 5 U.S.C. 8191. All statements made in this
report are true to the best of our knowledge and
belief.

26. Date Signed

27. Title

IMPORTANT: Please attach a copy of any investigation report of this injury and death. If no report was made, a statement from
each witness should be attached reporting what he saw, heard, or knows about the incident leading to injury and death.

ATTENDING PHYSICIAN'S MEDICAL REPORT
2. Date of Death (month, day, year)

1. Last, First, Middle Name of Deceased Officer

3. History of Injury

4. If Death Was Not Instantaneous, Describe Treatment Provided

5. Inclusive Dates on Which
Treatment Was Given

6. Direct Cause of Death

7. Contributory Cause of Death

8. In Your Opinion, Was Death of the Officer Due to the Injury as Reported in Item 3?
Your Reasons For Believing Death Resulted From Other Causes.

9. Was a Biopsy or Autopsy Performed?

Yes

10. I certify that the answers to the above questions
are true to the best of my knowledge and belief.
I am licensed to practice medicine and surgery
in the state of

No

Yes

No

If No, State

If So, By Whom?

11. Signature

12. Date Signed

13. Mailing Address Including ZIP Code

Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number. Public reporting burden for this collection of this information is estimated to average
60 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the
date needed, and completing and reviewing the collection of information. The authority for requesting this information is 5 U.S.C. 8101
et seq. The information will be used to determine entitlement to benefits. Furnishing the requested information is required for the
claimant to obtain or retain a benefit. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the U. S. Department of Labor, OWCP, Room S3229, 200 Constitution
Avenue, NW, Washington, DC 20210, and reference OMB Control Number 1240-0022. DO NOT SEND THE COMPLETED FORM
TO THIS ADDRESS.
Form CA-722a
Page 2 of 6
Rev. Mar 2010

Claim on Behalf of Widow, Widower, or Children
1. Last, First, Middle Name of Deceased Officer

2. Date of Death (month, day, year)

3. Mailing Address Including ZIP Code of Surviving Spouse or Guardian

4. Nature of Injury Which Caused Death

5. Name of Officer's Former Employing Organization

CLAIM OF
SURVIVING
SPOUSE

8. Number of Children Now Living
Who Are the Issue of This
Marriage

7. Was Spouse Living With Officer
at Time of Death?

6. Date of Marriage to Officer

Yes

No

10. Was the Officer Married at
Any Time to Anyone Else?

9. Was Spouse Married at Any
Time to Anyone Other Than
Officer?
No
Yes

Yes

11. Date of Birth of Surviving
Spouse

No

If answer to either items 9 or 10 is yes, submit documents to show dissolution of prior marriages, such as death
certificates, divorce decrees.
12. List all Children of the Officer for Whom Claim is Being Made (those living at the time of his death and who were under 18, or who were
over 18 and a student or incapable of self-support)
Living at
Address
If Not, Show Mailing Address
Date of
Shown in
Name
Birth
Item 3?

13. Has a Legal Guardian Been Appointed for Any of the Above-Named Children?
of Guardian of Each Child and Attach a Certified Copy of Appointment Documents

Yes

No

If Yes, Give Name and Mailing Address

14. List Any Other Relatives Who May be Entitled to Compensation
Date of Birth

Name

Relationship
to Officer

Mailing Address

15. Has Application Been Made for Compensation, Annuity, or Other Benefits as a Result of This Death Under Any Compensation Law, Police Death
or Survivor's Benefit Fund, or Other Such Fund?
Yes
No
If Yes, Give Name and Address of Organization With Which
Application Was Filed.

16. Was Officer Ever in the Armed
Forces of the United States?
Yes
No

A. Service Number

If Yes, Furnish
17. If Question 16 is Answered ''Yes,'' Has Application Ever Been Made for Compensation
or Pension on Account of Such Service?
Yes

No

No

C. Period of Service
From
Through

A. Claim Number

B. Name and Address of Office Where Claim is Filed

If Yes, Furnish

18. Has Application Ever Been Made for Any Annuity
on Account of Officer's Civilian Service With
the United States?
Yes

B. Branch of Service

A. Type of Annuity (e.g., civil service retirement)

B. Claim Number

If Yes, Furnish

19. I hereby make claim for compensation for the spouse and/or children listed above, under 5 U.S.C. 8101 et seq., as extended by 5 U.S.C.
8191, as a result of the death of the above-named officer, who sustained fatal injury while in the performance of duty. Every statement set
forth above is true to the best of my knowledge and belief.
(Signature of Claimant)
Page of 6

(Date)
FormCA-722b
CA-722b
Form
Rev.
Rev. Oct
Mar2001
2010

Claim on Behalf of Dependent Other Than Widow, Dependent Widower, or Children
1. Last, First, Middle Name of Deceased Officer

2. Date of Death (month, day, year)

3. Name of Officer's Former Employing Organization

4. Nature of Injury Which Caused Death

5. Last, First, Middle Name of Dependent
6. Dependent's Mailing Address Including ZIP Code
7. Dependent's Birth Date

12. Did Officer Live With
Dependent During the 12
Months Immediately Prior
to Officer's Death?
Yes
No

11. Amount Contributed
by Officer Toward
Dependent's Support
During the 12 Months
Immediately Prior
to Death

10. Dependency on Officer
Total
Partial

9. Relationship to Officer

8. Dependent's Social Security Number

A. Amount Paid by Officer to
Dependent in Money or
Service for Room and Board
in Addition to Contribution
Shown in Item 11.

B. If No Fixed Amount Was Paid
for Room and Board, What
is the Fair Value of Such
Room and Board?

If Yes, Furnish

13. Was Dependent Employed
During the 12 Months Immediately Prior to Officer's
Death?
Yes
No

A. Occupation (s)

B. Period Employed

C. Monthly Rate of Pay

If Yes, Furnish
14. In Addition to Employment, State Other Income From All Sources During the 12 Months Prior to Officer's Death.

15. At Time of Officer's Death
Was Dependent Married?
Yes

From People Other
Than Officer $

Pensions $

Investments $

A. Birth Date

B. Occupation

C. Total Income From All
Sources For 12 Months Prior
to Officer's Death

All Other Sources $
D. Monthly Rate of Pay

No

If Yes, Furnish
16. List All Property Owned by Dependent and/or Spouse (omit clothing, furniture). Give Approximate Market Value of Each Item and Date
Acquired

17. List Name and Relationship of Persons Dependent Upon This Dependent.

18. Has Application Been Made for Compensation, Annuity, or Other Benefits as a Result of This Death Under Any Compensation Law, Police Death
or Survivor's Benefit Fund, or Other Such Fund?
Yes
No
If Yes, Give Name and Address of Organization With Which
Application Was Filed.

19. Was Officer Ever in the Armed
Forces of the United States?
Yes
No

A. Service Number

If Yes, Furnish
20. Has Application Ever Been Made for Any Annuity
on Account of Officer's Civilian Service With
the United States?
Yes

No

B. Branch of Service

C. Period of Service
From
Through

A. Type of Annuity (e.g., civil service retirement)

B. Claim Number

If Yes, Furnish

21. I hereby make claim for compensation under 5 U.S.C. 8101 et seq., as extended by 5 U.S.C. 8191, as a result of the death of the
above-named officer, who sustained fatal injury while in performance of duty. Every statement set forth above is true to the best of my
knowledge and belief.

(Signature of Claimant)
Page 4 of 6

(Date)
Form CA-722c
Rev. Mar 2010

INSTRUCTIONS FOR COMPLETING THIS FORM
(Please do not detach)

1. GENERAL. This form is used to report a death sustained by a
non-Federal law enforcement officer under circumstances involving
a crime against the United States. Specifically, section 8191 of title
5, United States Code, provides Federal workmen's compensation
benefits for a person determined to have been on any given
occasion (1) a law enforcement officer and to have been engaged on
that occasion in the apprehension or attempted apprehension
of any person

3. ATTENDING PHYSICIAN'S MEDICAL REPORT. This report is to
be completed by a physician who examined or treated the deceased
officer. It is not necessary if a copy of a more complete medical report
is being submitted.
4. CLAIM ON BEHALF OF WIDOW, WIDOWER, OR CHILDREN. This
is a formal claim for death benefits on behalf of all those listed in the
claim, it may be submitted by -

(A) for the commission of a crime against the United
States, or

(1) any survivor of the deceased officer;
(2) any guardian, personal representative, or other person legally
authorized to act on behalf of the officer's estate or any of his
survivors; or

(B) who at that time was sought by a law enforcement
authority of the United States for the commission of a
crime against the United States, or

(3) any association of law enforcement officers acting on behalf
of the officer's survivors.

(C) who at that time was sought as a material witness in a
criminal proceeding instituted by the United States; or
(2) a law enforcement officer and to have been engaged on
that occasion in protecting or guarding a person held for the
commission of a crime against the United States or as a
material witness in connection with such a crime; or
(3) a law enforcement officer and to have been engaged on
that occasion in the lawful prevention of, or lawful attempt to
prevent, the commission of a crime against the United States;
and to have sustained a personal injury (including disease) resulting
in death, related to that occasion. Federal law enforcement officers
are excluded from section 8191.
If one of the above conditions is met, this form should be filed with the
Office of Workers' Compensation Programs if there are survivors
eligible for benefits or if there are any unpaid medical, funeral, or
transportation bills. The form is designed so that if there are no
eligible survivors who wish to file claim, then their portion of the form
may be detached.
If additional space is needed for any answer, attach a separate
sheet of paper and write, "see separate sheet," in the appropriate
box of this form. Please place the name of the deceased officer
(and case file number if known) to OWCP within 5 years from the
date of death. If there are no survivors, it is suggested that their
portion of this form be completed before the former employing
organization and the physician complete their portion.

Items 6 through 11 on this claim pertain to the surviving spouse and
should not be completed if no claim is being made on his or her
behalf, or if there is no surviving spouse. Item 12 asks for names of
surviving children. If there are more children than room to enter their
names, attach a separate sheet. This is very important. In the last line
of item 12 write, ''see attached sheet for names of additional children.''

In item 14 list anyone else for whom the officer was furnishing some
support at the time of his/her death. Include minor children from
his/her prior marriages even though the officer was not supporting
them prior to his/her death. Again, if more room is needed attach a
separate sheet.

The form and the attachments (please read paragraph 6 below)
should be sent to the officer's former employing organization.

5. CLAIM ON BEHALF OF DEPENDENT OTHER THAN WIDOW
WIDOWER, OR CHILDREN. This is a formal claim for death benefits
on behalf of one person. If more than one person listed below was
dependent on the deceased officer, write to the Office of Workers'
Compensation Programs for extra forms. This claim may be
submitted by (1) any survivor of the deceased officer;
(2) any authorized to act on behalf of the officer's estate or any
of his survivors; or

2. EMPLOYING ORGANIZATION'S REPORT. This report must be
completed in every instance by the deceased officer's former
employing organization. Wage information, duty hours, and like
information should be obtained from the organization's records. If the
organization disagrees with one or more of the statements made by
the survivors, it should submit a detailed explanation giving the
reasons for its disagreement.

Page 5 of 6

(3) any association of law enforcement officers acting on behalf
of the officer's survivors. Those dependents other than the
widow, widower, and children who may be eligible for benefits
include dependent parents, dependent grandparents, dependent
brothers, dependent sisters, and dependent grandchildren of the
officer. There is no provision in the law for other relatives.

Form CA-722
Rev. Mar 2010

(6) Dependent's birth certificate (needed only if claim is being
made by brother, sister, or grandchild of officer);

The form and the attachments (please read paragraph 6 below)
should be sent to the officer's former employing organization.

(7) As proof of relationship to the officer a grandparent
claiming compensation must provide the birth certificate of the
officer's mother or father, as appropriate; a grandchild
claiming compensation must provide the birth certificate of the
officer's son or daughter, as appropriate;

6. ATTACHMENT. There are several documents that must be
submitted in support of most claims. Sometimes they will not be
readily available. To avoid delays in processing this form, make
up a list of those documents that will be sent at a later date. Then
as documents are received send them directly to the Office of
Workers' Compensation Programs.

(8) A recent medical report describing disability for unmarried
dependents over age 18 who are basing their claim on mental
or physical disability (needed only if claim is being made by
widower, child, brother, sister, or grandchild); if this person is
committed to a public institution merely state the name and
address of the institution.

Needed are:
(1) Officer's death certificate (all cases);
(2) Birth certificates of all children claiming compensation; for
adopted children furnish orders of adoption instead of birth
certificates.
(3) Marriage certificate of spouse claiming compensation:
(4) Documents showing dissolution of prior marriages of officer
and of spouse, such as final divorce decrees, death certificates
(needed only if spouse is claiming compensation);
(5) Officer's birth certificate (needed only if claim is
being made by parent, grandparent, brother, or sister of officer);

Except for (8), all documents must bear the signature and seal
(imprint) of the public official having custody of such records. All
documents or records originating in a court of law must bear the
signature and seal (imprint) of the proper court official. Photostat
copies are not acceptable unless they bear the actual signature
and seal of the public official, not just a copy.
7. SUBMITTING THIS FORM. This form and available attachments
should be turned over to the officer's former employing
organization. The organization will have any remaining parts
completed. Afterwards, it should review the form and attachments
for completeness and to see that all signatures appear. If a report
of investigation of any type was made on the death or the incident
leading to death, a copy should be attached. When the form and
any statements and attachments are ready for transmission, this
instruction page should be removed. Only one copy of this form
(the original) need be submitted.

Privacy Act
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees'
Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation
Programs of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families.
(2) Information which the office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may
be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed
the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing,
and to consider issues relating to retention, rehire, or other relevant matters. (4) Information may also be given to other Federal agencies,
other government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and
services. (5) Information may be disclosed to physicians and other health care providers for use in providing treatment or medical/vocational
rehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (6) Information may
be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA,
to determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where
appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection
Act. (7) Disclosure of claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN,
and other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal
government, and for other purposes required or authorized by law. (8) &RPSOHWLRQRIWKLVIRUPLVYROXQWDU\KRZHYHUIailure to disclose all
requested information may delay the processingof the claim or the payment of benefits, or may result in an unfavorable decision or reduced

OHYHORIEHQHILWV
Note: This notice applies to all forms requesting information that you might receive from the Office in connection with the
processing and adjudication of the claim you filed under the FECA.
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number. Public reporting burden for this collection of this information is estimated to average
60 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the
date needed, and completing and reviewing the collection of information. The authority for requesting this information is 5 U.S.C. 8101
et seq. The information will be used to determine entitlement to benefits. Furnishing the requested information is required for the 
claimant to obtain or retain a benefit. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the U. S. Department of Labor, OWCP, Room S3229, 200 Constitution
Avenue, NW, Washington, DC 20210, and reference OMB Control Number 1240-0022. DO NOT SEND THE COMPLETED FORM
TO THIS ADDRESS.

All completed forms, documents, and inquiries should be sent to
OWCP, Dist Office 9, Cleveland
1240 East Ninth Street, Room 851
Cleveland, Ohio 44199
Page 6 of 6

Form CA-722
Rev. Mar 2010