Form ca-41 Claim for Survivor Benefits under FECA Section 8102a Dea





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OMB Number: 1240-0017
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1. Name (Last, First, Middle):
2. Sex:



Male



Female

3. Social Security Number:

4. Date of Birth (DOB):

5. Date of Death (DOD):

6. Employer on date of death:
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7. Name (Last, First, Middle):
8. Sex:



Male



Female

10. DOB:

9. Social Security Number:
11. Relationship to decedent (check boxes)





Spouse
Parent




Child



Step-Child

Sibling

Other: Please describe ____________________

12. Address:

13. Telephone Numbers:

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14. FECA Claim Number:

15. Date of Injury:

16. Position held on date of injury:

17. Employer at time of injury:

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18. Armed Force conducting the contingency operation in the region:



Army



Navy



Air Force



Marine Corps



Coast Guard

19. Place where injury/exposure occurred:

20. Description of injury/exposure which led to the employee’s death:


















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21. 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 #:

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Amount paid:

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Revised January 2010




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22. To your knowledge, did the employee complete a Designation of a Recipient of the Death
Gratuity Payment (CA-40)?
Yes
No
If yes, please provide a copy of the designation form with this application.

23. Are you aware of any other person(s) who might also qualify as a survivor of the employee?
Yes
No
If yes, please provide the following information:
Name

Relationship to
decedent

Address

Phone Number(s)



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I hereby certify that each and every statement made above is true and accurate to the best of
my knowledge. Any person who knowingly makes any false statement, misrepresentation,
concealment of fact, or any other act of fraud to obtain compensation as provided by 5 U.S. C.
8102a or who knowingly accepts compensation to which that person is not entitled is subject
to felony criminal prosecution and may, under appropriate criminal provisions, be punished by
a fine or imprisonment or both.

Claimant signature: _________________________________ Date: ____________________

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Complete all items on the form. If additional space is required to explain or clarify, attach a supplemental
statement to the form. If the requested information is not submitted, the responsible party should explain the
reason(s) for the delay and indicate when the information will be forthcoming. Submit the completed form
and all other pertinent documentation to the Cleveland district office of the Department of Federal
Employees’ Compensation.
,WHP - Survivors are defined as follows:
x A spouse is the person legally married to the deceased employee at the time of death.
x A child refers to the employee’s natural children, adopted children, and some stepchildren. A
stepchild must have been a part of the employee’s household (i.e. a part of the household per a written
custody agreement or actually sharing a home for the majority of the time) at the time of death. For a
natural child who is an illegitimate child of a male employee, the child must satisfy one of the criteria
listed in 5 U.S.C. 8102a.
x Surviving parents include fathers and mothers through adoption and persons who stood in loco
parentis to the employee for a period of not less than one year at any time before the person became
an employee. A person will be considered in loco parentis when the person takes the employee into
his or her home and treats them as member of his or her family, providing parental supervision,
support, and education as if the employee were his or her own child. Only one father and one mother
or their counterparts in loco parentis may be recognized. Preference is given to those who exercise a
parental relationship on the date, or most nearly before, the date on which the decedent became an
employee.

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,WHP – If the claimant filed a claim for injury prior to the date of death, provide the claim number
assigned to that claim.
,WHP – If a claim was filed (see #14), then this is the date that will be utilized. If the employee did not
file a claim for compensation for the injury which led to the employee’s death, the date of injury will need to
be determined. If the traumatic injury was a definite occurrence which can be assigned to a time and place
during one work day or shift, then this date will be used as the date of injury. If the employee’s death resulted
from an occupational illness which developed over more than one day or work shift, then the date of injury
will be the date that the employee became aware (or reasonably should have been aware) of the relationship
between the illness and factors of employment.
,WHP – For purposes of this benefit, the term “employee” has the meaning as stated in 5 U.S.C. 8101 and
also includes Non-Appropriated Fund Instrumentality (NAFI) employees as defined in section 1587(a)(1) of
Title 10 of the United States Code.
,WHP – For the purposes of this benefit, the term “armed forces” is limited to the options provided herein.
The term “contingency operation” includes a basic contingency operation, humanitarian operations,
peacekeeping operations, and similar operations. The definitions of these types of operations can be found in
title 10 of the United States Code.
,WHP – List other payments made for a death gratuity only (not those made for death under section 8133
of the FECA, retirement, life insurance, or any other federal benefit). Death gratuities that could be paid
include but are not limited to: payment under section 413 of the Foreign Service Act of 1980; the gratuity
provision of the Emergency Supplemental Appropriations Act for Defense, the Global War on Terror, and
Hurricane Recovery, 2006; the $10,000 death gratuity to the personal representative of civilian employees, at
Title VI, Section 651 of the Omnibus Consolidated Appropriations Act of 1996 (Public Law 104-208,
September 30, 1996); the death gratuity for members of the armed forces or any employee of the Department
of Defense dying outside the United States while assigned to intelligence duties, at 10 U.S.C. § 1489; and the
death gratuity for employees of the Central Intelligence Agency, at 50 U.S.C. § 403k.
,WHP – For a definition of eligible survivors, see the instructions above for item 11. If you answered
‘yes’ to item 22, please list any beneficiaries designated by the deceased employee here along with current
contact information.
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Previous editions obsolete

CA-41
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Revised January 2010