Benefits Package and Supporting Documentation

Date

Mr./ Ms. Full Name

Address

Address

Case Number:

Dear Mr./Ms. Last Name:

The Countermeasures Injury Compensation Program (CICP or the Program) has determined that [Deceased Countermeasure Recipient name]’s death was directly caused by the use or administration of the [covered countermeasure], as stated in our [date of letter] letter.

Required Eligibility Documentation

You submitted a Request for Benefits Form in which you indicated that you are a survivor of [Deceased Countermeasure Recipient name]. In order for the Program to determine your eligibility for death benefits, you must submit the following documentation, if you have not already done so:

• A death certificate for [Deceased Countermeasure Recipient name]. If a death certificate is unavailable, you must submit a letter providing the reasons for its unavailability and alternative documentation showing that [Deceased Countermeasure Recipient name] is deceased. The Program has the discretion to accept other documentation as evidence that [Deceased Countermeasure Recipient name] has died. The Program expects that the unavailability of the death certificate will be a rare occurrence.

• Documentation showing that you are an eligible survivor (e.g., birth certificate or marriage certificate). The categories of eligible survivors are explained below.

• If there are multiple eligible survivors and one (or more) of them dies before the Program pays the death benefit, you can amend the Request Form to remove them; also provide a copy of that person’s or persons’ death certificate(s).

These materials must be received within 60 calendar days of the date of this letter. This is all the documentation you are required to submit at this time. Please inform the Program if you need more time.

The information provided below explains the types of Program benefits that may be available to a survivor of a deceased injured countermeasure recipient, and their limitations. You may submit documentation related to these potential benefits at this time, or you may do so after the Program informs you of its eligibility determination.

Potential Death Benefits

Death benefits under the CICP may be available under one of two different calculations: the “standard calculation” or the “alternative calculation.” The “standard calculation” is a lump-sum payment to eligible survivors. In general, this method is based on the death benefit available under the Public Safety Officers’ Benefits (PSOB) Program. For more information on the PSOB Program, please see: https://www.psob.gov. For deaths occurring in Fiscal Year [FY that Deceased Countermeasure Recipient Died], the total death benefit amount is $[PSOB payment for that year].

The “alternative calculation” is only available to surviving dependents who are younger than the age of 18. This method is based on the deceased countermeasure recipient’s employment income at the time of the covered injury.

Categories of Eligible Survivors and the Order of Priority for Payments of Death Benefits

Standard Calculation:

In order to be considered for the standard calculation of the death benefit, the survivor must be in one of the categories listed below. For a survivor to be eligible under categories four through six, there can be no individual in a higher priority category. The standard calculation of the death benefit is disbursed in the following order of priority:

1. If there is no surviving child of [Deceased Countermeasure Recipient name], to [Deceased Countermeasure Recipient name]’s surviving spouse.

A spouse will qualify for CICP benefits if they qualify as a spouse under the PSOB Program. Generally, a spouse refers to an individual’s lawful husband, wife, widower, or widow. Certain common law marriages may qualify in states that recognize common law marriages. An eligible spouse who is separated but not legally divorced may be considered for death benefits.

2. If there is at least one surviving child of [Deceased Countermeasure Recipient name] and a surviving spouse, fifty percent to the surviving child (or children in equal shares) and fifty percent to the surviving spouse.

A surviving child will qualify under this category if they are a natural, illegitimate, adopted, or posthumous child, or stepchild of a deceased injured countermeasure recipient who, at the time of the countermeasure recipient’s death, is:

• 18 years old or younger, or

• between 19 and 22 years of age and a full-time student, or

• incapable of self-support due to a physical or mental disability, regardless of age.

Surviving dependents younger than the age of 18 (as defined below under the “Alternative Calculation” section) have the same priority as surviving children as defined here.

3. If there is no surviving spouse, to the child (or children in equal shares).

4. If there is no surviving spouse or child, to the named Beneficiary.

In the event that the injured countermeasure recipient dies without a spouse, child, or dependent minor, then the person(s) named in a beneficiary designation form supplied by an employer or, if no such form exists, the most recently executed insurance policy may be eligible for death benefits. The individual(s) may receive the entire death benefit if there is no spouse, no child, and no minor dependent.

5. If none of the above, to the surviving parent (or parents in equal shares) of [Deceased Countermeasure Recipient name].

In the event that there is no spouse, no child, no minor dependent, and no named Beneficiary, then the two parents may divide the death benefit into equal shares. If there is only one surviving parent, then they would receive the entire benefit.

6. If none of the above, to the legal guardian of a deceased minor without surviving parents.

If the deceased injured countermeasure recipient was a minor, then their legal guardian, if other than a parent (such as a grandparent), may receive the death benefit if there are no other survivors as listed above.

7. If none of the above, to the adult child (or children in equal shares) of [Deceased Countermeasure Recipient name].

In the event that there is no spouse, no child as defined under category two above, no minor dependent, no named Beneficiary, and no surviving parent, then the death benefit may be paid to the individual(s) who would qualify as surviving child(ren) under category two above, but for age.

Alternative Calculation:

There is an additional category of survivors who may be eligible for the alternative calculation of the death benefit. This category is:

1. Dependent(s) younger than the age of 18.

A person whom the Internal Revenue Service would consider to be the deceased injured countermeasure recipient’s dependent at the time the covered injury was sustained and who is younger than the age of 18 at the time of the filing of the Request for Benefits. This category may include individuals who would also qualify as a surviving minor child (as defined under category two in the “Standard Calculation” section above) as well as dependents other than the decedent’s children, such as nieces, nephews, foster children, or other minors. The legal guardian of a minor who would qualify as a child under category two for the standard calculation and as a minor dependent for the alternative calculation will have to request one of the two types of death benefits. Surviving dependents younger than the age of 18 under this category have the same priority as surviving children as described under section two for the standard calculation.

Payer of Last Resort

Under the standard calculation, the CICP is the payer of last resort and can only disburse death benefits less the amount of a temporary and partial disability benefit that has been or will be paid under the PSOB Program. No death benefit will be paid under the standard calculation if a death benefit is paid for the deceased injured countermeasure recipient, or if survivors are eligible to receive a death benefit under the PSOB Program.

Under the alternative calculation, the CICP is the payer of last resort and can only disburse death benefits less the amount covered by other third-party payers. Third-party payers are organizations that are responsible for paying benefits with respect to the deceased injured countermeasure recipient, such as a life insurance company, employer (e.g., Workers’ Compensation), or a government program (e.g., Department of Veterans Affairs).

Benefits Documentation

The description of additional documentation required by the CICP to calculate death benefits is listed below. If you would like to submit this documentation now, you may do so, but it is not required at this time.

For the standard calculation:

• Certification of Status for Death Benefits – Standard Calculation (Attachment 1) informing the Program whether a disability or death benefit was paid or is payable under the PSOB Program because the deceased countermeasure recipient was a Public Safety Officer or was otherwise eligible to receive a PSOB Program benefit. If a PSOB benefit was provided, you must submit documentation showing the amount of the benefit. If [[Deceased Countermeasure Recipient name] was covered under the PSOB Program and no benefit was or will be provided to them, you indicate in the certification whether any survivors are eligible for a death benefit under the PSOB Program and, if so, whether a death benefit may be paid or payable under the PSOB Program. If a dependent has more than one legal guardian, only one guardian must complete and sign this form. If there are multiple dependents, a separate Certification must be completed and signed for each dependent by one guardian.

• Certification of Relationship to Deceased Injured Countermeasure Recipient (attachment 3) - this documentation is used to verify your relationship to the deceased injured countermeasure recipient and indicate, to the best of your knowledge, whether there are additional potentially eligible survivors.

For the alternative calculation:

The “alternative calculation” is only available to surviving dependents who are younger than the age of 18. If a dependent has more than one legal guardian, only one guardian must complete and sign this form. If there are multiple dependents, a separate Certification must be completed and signed for each dependent by one guardian.

• Documentation showing that [[Deceased Countermeasure Recipient name] is survived by one or more dependents younger than the age of 18. Such documentation must show the date of birth of all such dependents (e.g., copies of birth certificates);

• Documentation showing that the requester is the legal guardian of all of the dependents. If multiple dependents have different legal guardians, the legal guardian of each of the dependents must submit such documentation;

• Documentation showing [[Deceased Countermeasure Recipient name]’s gross employment income at the time the covered injury was sustained (e.g., the decedent’s Federal tax return or pay stub(s) from all employers at the time of the covered injury); and

• Certification of Status for Death Benefit – Alternative Calculation (Attachment 2) providing a description of all third-party payers that have paid for, or that are obligated to pay for life insurance, compensation for loss employment income, and/or disability, retirement, or death benefits. This description must include the amount of such benefits that have been paid or that may be paid in the future. If there is no known third-party payer, the requester must select Option 1 on this Certification Form.

Please submit the requested forms online at injurycompensation.hrsa.gov (preferred). If you cannot submit the form electronically, please send the required documentation to the address below:

Health Resources and Services Administration

Countermeasures Injury Compensation Program

5600 Fishers Lane, 8W-25A

Rockville, MD 20857

The Program requests that you send all requested materials within 60 calendar days of the date of the enclosed letter. If you have any questions, please contact the CICP at 1-855-266-2427, email [email protected], or mail them to the address above.

Sincerely,

________________________________ __________________

CDR George Reed Grimes, M.D., M.P.H. Date

Director, Division of Injury Compensation Programs

Enclosure:

Attachment 1 – Certification of Status for Death Benefit – Standard Calculation

Attachment 2 – Certification of Status for Death Benefit – Alternative Calculation

Attachment 3 – Certification of Relationship to Deceased Injured Countermeasure Recipient

Health Resources and Services Administration

www.hrsa.gov