Form ca-42 Official Notice of Employees' Death for Purposes of FECA

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U.S. DEPARTMENT OF LABOR

Office of Workers’ Compensation Programs
Division of Federal Employees' Compensation
OMB Number: 1240-0017
Expiration Date: xx-xx-xxxx

Official Notice of Employees’ Death for Purposes of FECA Section 8102a Death Gratuity
(CA-42)
Instructions on Completing Form CA-42. Complete each item as completely as possible and
include a copy of the death certificate and a copy of the most recent CA-40 beneficiary
designation. Please sign and date the form noted on page 4 and forward it to Office of Workers’
Compensation Programs’ Division of Federal Employees’ Compensation.
Deceased Employee Information
1. Name (Last, First, Middle):
2. Sex:

Male

Female

4. Date of Birth (DOB):

3. Social Security Number:
5. Date of Death (DOD):

6. Employing Agency:
7. Employee’s position with the agency:

Circumstances of the Employees’ Injury/Death
8. Date and hour of injury:
9. Location where the injury occurred:
10. Date that the employee’s immediate supervisor first had knowledge of the injury:
11. Describe how the injury occurred:

12. Was the employee in the performance of duty when the injury occurred?

Yes

No

13. What were the employee’s assigned duties at the time of death?

CA-42
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November 2009

Circumstances of the Employees’ Injury/Death (Cont’d)
14. Were the employee’s duties being performed in connection with an Armed Force
contingency operation?
Yes
No
If yes, please indicate which Armed Force and what operation.
Include a copy of the employee’s death certificate with this form.

Survivor Information
15. Did the employee complete a Designation of a Recipient of the Death Gratuity Payment
(CA-40) or otherwise indicate, in writing, a designation?

□ Yes □ No

If yes, provide a copy of the form CA-40 or other pertinent written documentation.
Include any completed CA-41 forms the employee’s agency received from survivors or
alternate beneficiaries.
16. Did the employee have any living survivors or alternate beneficiaries?
Please list all potential beneficiaries.
Name

Relationship
to decedent

Address

□ Yes □

No

Phone
Number(s)

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November 2009

Other Death Gratuity Benefits Paid
17. Were any death gratuity benefits paid under any other law of the United States for this
death? □ Yes □ No
If yes, please provide the following information:
a.

Administering agency:
Contact:

Phone:

Address:
Claim #:

Amount paid:

b. Administering agency:
Contact:

Phone:

Address:
Claim #:

Amount paid:

c. Administering agency:
Contact:

Phone:

Address:
Claim #:

Amount paid:

Employing Agency Certification
As a representative of the employing agency, I hereby certify that the information provided
above concerning coverage of the employee under section 8102a of the Federal Employees’
Compensation Act is true and accurate to the best of my knowledge and belief.
Signature of Agency Official: ______________________________

Date:______

Official Name: ______________________________________________________________
Official Title:: _______________________________________________________________
Address: ___________________________________________________________________
Phone: ____________________________________________________________________
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November 2009

Privacy Act Statement
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 (FECA), as amended and extended (5 U.S.C. 8101, et seq.) including the Death Gratuity in section 1105 of
Public Law 110-181 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 entitlement to benefits or other relevant matters. (4) 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. (5) Disclosure of the claimant's social
security number (SSN) or tax identifying number (TIN) on this form is mandatory (Executive Order 9397, dated November 22, 1943).
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. (6) Failure to disclose all
requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or
reduced level of benefits.

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 number. Public reporting burden for this collection of information is estimated to average 20 minutes
per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing
and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefit (5.
U.S.C. 8102a). Send comments regarding the burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the Office of Workers’ Compensation Programs, U.S. Department of Labor, Room S3524,
200 Constitution Avenue, N.W., Washington, D.C. 20210, and reference the OMB Control Number 1240-0017. Note: Do not
submit the completed claim form to this address. Completed notices are to be submitted to the appropriate district office of the
Office of Workers’ Compensation Programs.

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November 2009