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

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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: 07/21/2023

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 3 and forward it to Office of Workers'
Compensation Programs' Division of Federal Employees' Compensation.

Request for Accommodations or Auxiliary aids and Services.

If you have a disability, Federal law gives you the right to receive help from the OWCP/DFEC in the form of communication assistance,
accommodation(s) and modification(s) to aid you in the claims process. For example, we will provide you with the copies of documents in
alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to accommodate
your disability. Please contact our office or your OWCP claims examiner to ask about this assistance.

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?

If you have a disability and are in need of communication assistance (such as alternate formats or sign language
interpretation), accommodations and/or modifications, please contact OWCP. See Instructions for additional details.
CA-42 PAGE 1 (Rev. 05-16)

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

Yes

Address

No

Phone Number(s)

CA-42 PAGE 2 (Rev. 05-16)

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:
CA-42 PAGE 3 (Rev. 05-16)

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.

CA-42 PAGE 4 (Rev. 05-16)