CA-5B Claim for Compensation by Parents, Brothers, Sisters, Gr

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U.S. Department of Labor

Claim for Compensation by Parents,
Brothers, Sisters, Grandparents, or
Grandchildren

Office of Workers' Compensation Programs

2. Date of Birth
(Mo., day, year)

1. Name of deceased employee (Last, first, middle)

7. Nature of injury which caused death

6. Name and address of employing agency (Include ZIP Code)

10. Dependent's birth date
(Mo., day, year)

9. Dependent's address (Include ZIP Code)

8. Name of dependent (Last, first, middle)

12. Dependent's Social
Security Number

11. Dependent's Occupation

4. Date of Death
(Mo., day, year)

3. Date of Injury
(Mo., day, year)

OMB No. 1240-0013
Expires: XX-XX-XXXX
5. Social Security Number

13. Dependent's relationship to
employee

14. Extent of dependency on
employee

17. Total amount employee paid
dependent in money or service
for room and board in addition to
amount shown in 15.

18. If no fixed amount was paid
for room and board, what is
the fair value of such room
and board?

Total
15.Total amount employee
contributed to dependent's
support during 12 months
immediately prior to death.

16. Did employee live with
dependent during the 12
months immediately prior
to death?
Yes
No
$
If ''Yes'', Complete 17 & 18.
19. If dependent was employed during 12 month period prior to
employee's death, give:
Type of work performed:

$

Per

$

Investments

$

Pensions

Monthly pay rate:

Persons other than employee

Name and address of employer:

Other
$

Total
Information about dependent's husband or wife (Items 21 through 25)
21. Birth Date (Mo., day, year) 22. Occupation
23. Monthly pay rate
$

24. Total income from all sources for 12 months prior to
employee's death. $

25. List all property owned by dependent and husband or wife (omit clothing, furniture, personal items).
Date Acquired
Description

26. If an application has been made for U.S. Civil Service Annuity or any
other Federal Retirement or Disability Law because of employee's
death, give:
CSRS

FERS

SSA
a.

Claim number for each claim:

b.
a.

Date each benefit began:

b.

Amount of each benefit paid per month:
29. Total burial expense
$

Per

20. Show dependent's income from all sources other than employment
during 12 month period prior to employee's death:

Period of employment:

Retirement System:

Partial

$

Other

Value

27. If an application has been made for Veterans Administration (VA)
benefits because of employee's death, give:
Service number:

VA Claim number:

Address of VA office where claim is filed:

28. If a claim has been made against a third party because of employee's death,
give:
Amount of recovery:

$

Name and address of third party:

a.

b.
30. Amount of burial expense paid 31. Name and address of party (other than VA) whose funds were used to pay burial expense
or payable by VA
and amount paid:
$

$

32. Name of Financial Institution for Depositing Benefits:
33. Account number:

Checking

Savings

34. Routing or transit number:

I hereby certify that each and every statement made above is true 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 the FECA 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.

35. Signature of person filing claim
Previous Edition Obsolete

36. Address (Include ZIP Code)

37. Date
(Mo., day, year)

Form CA-5b (Rev. 04-13)

Attending Physician's Report

1. Name of deceased employee (Last, first, middle)

2. Date of death (Mo., day, year)

3. What history of injury or employment related disease was given to you?

4. If treated for disease, give diagnosis.

5. If death was not instantaneous, describe the treatment you provided.

6. Show dates on which treatment
was given.

7. What was the direct cause of death?

8. What were the contributory causes of death, if any?

9. In your opinion, was the death of the employee due to the injury as reported in item 3 above?
Give the medical reasons for your opinion, unless causal relationship is obvious.

10. Was a biopsy or an autopsy performed?
Arrange for a copy of the report to be submitted.

Yes

Yes

No

No

11. Name and address (Please type - include ZIP Code)

I certify that all statements in response to the questions asked above are true, complete and correct to the best of my knowledge.
Further, I understand that any knowingly false or misleading statement or concealment of material fact may subject me to felony
criminal prosecution.
12. Signature

Previous Edition Obsolete

13. Date signed (Mo., day, year)

Form CA-5b PAGE 2 (Rev. 04-13)

INSTRUCTIONS FOR COMPLETING FORM CA-5b, CLAIM FOR COMPENSATION
BY PARENTS, BROTHERS, SISTERS, GRANDPARENTS OR GRANDCHILDREN

Who Should
File Claim

•

This claim form should be completed and filed by the deceased employee's parents,
grandparents or representative (custodian or guardian) of minor brothers, sisters or
grandchildren. A separate form is required for each person claiming benefits.

When Should
Claim Be Filed

•

Claim must be filed within three years following date of death, unless the
decedent's immediate superior had actual knowledge of an on-the-job injury or
death within 30 days; or written notice of the injury or death was given within 30
days. The timely filing of a disability claim will satisfy the time requirements for a
death claim based on the same injury.

What Documents
Are Required

•

The birth certificate of the deceased employee; also a death certificate if not previously submitted; birth certificates for minor brothers, sisters and grandchildren. If
claim is made on behalf of a grandparent, birth certificate of decedent's mother or
father, as appropriate. If claim is made on behalf of a grandchild, birth certificate of
decedent's son or daughter as appropriate. Copies of certificates or documents are
acceptable only if they are certified by the person having official custody of such
records. They should then be attached to the claim form when it is filed.

How to
Complete Claim

•

All items on the claim form should be completed. If an item is not applicable, indicate by
showing "NA". Note that the claim form requests information about several categories of
persons, i.e., items 1-7 make inquiry about the decedent; 8-20 the dependent; 21-25 the
dependent's husband or wife, if married at the time of employee's death. The attending
physician's report on the reverse of the form must also be completed before the form is
is submitted to the OWCP.

Funeral/Burial
Allowance

•

Submit original itemized funeral and burial bills. If paid, so indicate and give name and
address of person making payment. if an Administrator or Executor has been
appointed, give such person's name and address and attach a copy of the appointment
document.

See the following page for a definition of dependents and a description of benefits.

Previous Edition Obsolete

Form CA-5b PAGE 3 (Rev. 04-13)

DEATH BENEFITS FOR PARENTS, BROTHERS, SISTERS, GRANDPARENTS
AND GRANDCHILDREN UNDER THE FEDERAL EMPLOYEES' COMPENSATION ACT (FECA)

Eligible
Dependents

•

Benefits are payable on behalf of partially or totally dependent parents, brothers, sisters,
grandparents and grandchildren.

Period Of
Entitlement

•

Parents and grandparents: Payments continue until death, remarriage or termination of
dependency.
Minor brothers, sisters and grandchildren: Payments continue until death, marriage or
attainment of 18 years of age. Payments may continue beyond 18 if the child is mentally or
physically incapable of self-support or is a "full-time" student. Student benefits terminate on:
marriage, completion of 4 years of education beyond high school level, or at age 23,
whichever occurs first.

Compensation
Rates

•

For parent - 25% of the employee's monthly pay, if one is wholly dependent and the other is
not dependent at all. If both are wholly dependent - 20% each. A proportionate amount is
paid if either or both are partially dependent.
Brothers, sisters, grandparents, and grandchildren - 20% if only one is wholly dependent. If
more than one is wholly dependent - 30% shared equally. If one or more is partially dependent
- 10% shared equally if more than one.

Direct Deposit
Information

•

The Department of Treasury requires all Federal payments be made by electronic funds transfer (EFT),
also called Direct Deposit. You may submit a completed SF-1199A, Direct Deposit Sign Up, or complete
the information in items 32 through 34 of this form. If you do not have a bank account, you may be
required to receive your payment through Direct Express Debit MasterCard. To request information on the
Direct Express Debit MasterCard, go to www.usdirectexpress.com or call 1-800-333-1795. If directed to
enroll in the Program, you may contact for the Department of Treasury at 1-888-224-2950 to address any
questions or concerns you may have, as well as apply for a waiver from the process. NOTE: payments to
residents of foreign countries are exempt from the Treasury requirement.

Social Security
Benefits

•

If the employee was covered under the Federal Employees's Retirement System (FERS), 5
USC 811 (d)(2) requires that Social Security benefits payable to beneficiaries, which are
attributable to the deceased employee's Federal Service, are deducted from the beneficiary's
compensation entitlement.

Payment
Priorities

•

Monthly payments for all beneficiaries cannot exceed 75% of the employee's monthly
salary or 75% of the top step of GS-15 of the General Schedule. The surviving widow or
widower and children have first priority. Other eligible dependents may receive payment only if
the widow or widower and children's percentages are less than 75%.

Funeral/Burial
Allowance

•

Funeral and burial expense up to a maximum of $800 may be paid. Amount paid by
the VA will be deducted. If death occurs away from the employee's duty station,
transportation costs may be paid to return the deceased employee to his home or
last place of residence. In addition to any funeral or burial expenses, a sum of $200
may be paid for reimbursement of the costs of termination of the decedent's status
as an employee of the United States.

Third Party
Action

•

If the employee's death was caused by a person or party other than the Federal
Government, a ''third party action'' or lawsuit may be indicated. In such instances the
Department of Labor will provide further instructions.

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Form CA-5b PAGE 4 (Rev. 04-13)

Privacy Act Notice
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/adminsitrative offset and debt collection actions required or permiotted by the FECA and/or the Debt Collection Act. (7)
Disclosure of the claimaint'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
govoenrment, and for other purposes required or authorized by law. (8) Failure to disclose all requested ifnormation may delay the processing
of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.
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
Public reporting burden for this collection of information is estimated to average 90 minutes per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation
to respond to this collection is required to obtain or retain a benefit (5 U.S.C. 8101 et seq.). Send comments regarding this 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 S-3229, 200 Constitution Avenue, N.W., Washington, D.C. 20210, and reference the OMB Control Number 1240-0013.
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C. 20402

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.

Previous Edition Obsolete

Form CA-5b PAGE 5 (Rev. 04-13)