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: 07/21/2023

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:

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-41 PAGE 1 (Rev. 05-16)

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 #:

Amount paid:
CA-41 PAGE 2 (Rev. 05-16)

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)

24. Name of Financial Institution:
Account Type:

Checking

Savings

25. Account Number:
26. Routing or Transit Number:

Survivor Declaration
I certify that the information provided above is true and accurate to the best of my knowledge and
belief. 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. 8102, or who
knowingly accepts compensation to which that person is not entitled is subject to civil or
administrative remedies as well as criminal prosecution and may, under appropriate criminal
provisions, be punished by a fine or imprisonment, or both. In addition, a state or federal criminal
conviction for FECA fraud will result in termination of all current and future FECA benefits.
Claimant signature:

Date:
CA-41 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 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.

CA-41 PAGE 4 (Rev. 05-16)

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.
Request for Accommodation 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.
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 Non-Appropriated
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.
Items #24 through #26 – The Department of the Treasury requires all Federal payments be made by electronic funds transfer (EFT), also
called Direct Deposit. If you have not previously signed up to receive compensation with EFT, or desire to change your current account
information, please submit SF-1199A, Direct Deposit Sign Up. 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 the Department of the 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 requirements.
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.

CA-41 PAGE 5 (Rev. 05-16)