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

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U.S. DEPARTMENT OF LABOR

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

Claim for Survivor Benefits Under the Federal Employees' Compensation Act Section 8102a
Death Gratuity (CA-41)
Deceased Employee Information
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:

Survivor Information
7. Name (Last, First, Middle):
8. Sex:

Male

Female

10. DOB:

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

Child

Parent

Sibling

Other:

Step-Child

Please describe

12. Address:
13. Telephone Numbers:

Injury/Occupational Illness Information
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:

Other Death Gratuity Benefits Paid
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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Other Potential Survivors
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)

Survivor Declaration
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:

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Date:

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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 control number. Public reporting burden for this collection of information is estimated to average
15 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: Please do not submit the completed claim form to this address. Completed claims are to be submitted to
the appropriate district office of the Office of Workers’ Compensation Programs.
ACCOMMODATION STATEMENT
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to
receive help from OWCP in the form of communication assistance, accommodation and modification to aid you in the claims
process. For example, we will provide you with copies of documents in alternate formats, communication services such as sign
language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact
our office or your claims examiner to ask about this assistance.

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CA-41 Instructions
This form is to be used by survivors to claim the FECA Death Gratuity benefit.
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.
Item #11 - Survivors are defined as follows:
• A spouse is the person legally married to the deceased employee at the time of death.
• 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.
• 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.
Item #14 – If the claimant filed a claim for injury prior to the date of death, provide the claim number assigned to that claim.
Item #15 – 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.
Item #16 – For purposes of this benefit, the term “employee” has the meaning as stated in 5 U.S.C. 8101 and also includes NonAppropriated Fund Instrumentality (NAFI) employees as defined in section 1587(a)(1) of Title 10 of the United States Code.
Item #18 – 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.
Item #21 – 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.
Item #23 – 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.
Any person signing this form avers that person is either a survivor or beneficiary of a covered employee or is entitled,
by law, to sign a claim on behalf of the named survivor or beneficiary.

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