CA-722 Notice of Law Enforcement Officer's Death

Notice of Law Enforcement Officer's

Death

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U.S. Department of Labor
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Office of Workers' Compensation Programs
OMB No. 1240-0022
Expires: 10/31/2026

Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB
control number.
1. Name and Mailing Address Including ZIP Code of
Employing Organization

EMPLOYING ORGANIZATION'S REPORT
2. Name of Deceased Officer's Immediate Superior
3. Name and Telephone Number of Person to Contact

4. Last, First, Middle Name of Deceased Officer

5. Officer's Birth Date (month, day, year)

6. Social Security Number

7. Officer's Last Mailing Address Including ZIP Code
8. Date and Hour of Injury

10. Date and Hour Pay Stopped

9. Date of Death

AM
PM

PM

11. Rate of Pay on Date of Injury

12. List and Show Value of Other Pay Increments on Date of injury

Base

$

Per

Subsistence, If Extra

$

Per

$

Per

Quarters, If Extra

$

Per

$

Per

13. On Day of Injury
Officer's Shift

a. Began
AM

b. Ended
AM

PM

PM

16. Did Officer Work for the Organization a Full 11
Months Immediately Prior to Injury?
Yes

AM

14. Number of Hours Worked
Per Day (exclusive of overtime)

15. Circle Days Normally Worked
Per Week (exclusive of overtime)
SU MO TU WE TH FR SA

17. If No, Would His Job Have Afforded Employment For
11 Months Except For the Injury?
Yes

No

No

18. Describe Nature of Injury Which Caused Death

19. Describe Fully How the Officer's Death Occurred While Enforcing the Laws of the United States. If possible, give the U.S. Code Citation.

20. Was Officer Performing Regular Duties When Injured? If No, Give Full Explanation

Yes

No

21. Was the Injury Caused By:
a. Officer's Willful Misconduct?

Yes

No

b. Officer's intoxication?

Yes

No

c. Officer's Intent to Bring About Injury to Self or Another (other than normally required in performance of duty)?
Attach Detailed Explanation for Any ''Yes'' Answers
22. If Known, Give Name and Address of Suspect(s) or Witness(es) With Whom Officer Was Involved When Injured

Yes

No

23. Has Application Been Made for Compensation, Annuity, or Other Benefits as a Result of This Death Under Any Compensation Law, Police Death or
Survivor's Benefit Fund, or Other Such Fund?
Yes
No
If Yes, Give Name and Address of Organization With Which Application Was Filed.

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.
Page 1 of 6

Form CA-722a
Rev. Oct. 2022

24. Define, Explain, or Identify the Circumstances of This Injury Resulting in Death Which Involves the
United States (see the first paragraph of the instruction sheet attached to this form).

25. Signature
We hereby certify that the officer, whose death is
reported above, was injured while in performance of
duty under 5 U.S.C. 8101 et seq., as extended by 5
U.S.C. 8191. All statements made in this report are
true to the best of our knowledge and belief.

26. Date Signed

27. Title

IMPORTANT: Please attach a copy of any investigation report of this injury and death. If no report was made, a statement from each
witness should be attached reporting what he saw, heard, or knows about the incident leading to injury and death.

ATTENDING PHYSICIAN'S MEDICAL REPORT
2. Date of Death (month, day, year)

1. Last, First, Middle Name of Deceased Officer

3. History of Injury

4. If Death Was Not Instantaneous, Describe Treatment Provided

5. Inclusive Dates on Which
Treatment Was Given

6. Direct Cause of Death

7. Contributory Cause of Death

8. In Your Opinion, Was Death of the Officer Due to the Injury as Reported in Item 3?
Your Reasons For Believing Death Resulted From Other Causes.
9. Was a Biopsy or Autopsy Performed?

Yes

10. I certify that the answers to the above questions are
true to the best of my knowledge and belief. I am
licensed to practice medicine and surgery in the state of

No

Yes

No

If No, State

If So, By Whom?

11. Signature

12. Date Signed

13. Mailing Address Including ZIP Code

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 this information is estimated to average 90 minutes per response, including time
for reviewing instructions, searching existing data sources, gathering and maintaining the date needed, and completing and reviewing the collection of
information. The authority for requesting this information is 5 U.S.C. 8101 et seq. The information will be used to determine entitlement to benefits.
Furnishing the requested information is required for the claimant to obtain or retain a benefit. Send comments regarding the burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to the U. S. Department of Labor, OWCP, Room S3229, 200
Constitution Avenue, NW, Washington, DC 20210, and reference OMB Control Number 1240-0022. DO NOT SEND THE COMPLETED FORM TO THIS
ADDRESS.
Form CA-722a
Page 2 of 6
Rev. Oct. 2022

Claim on Behalf of Widow, Widower, or Children
1. Last, First, Middle Name of Deceased Officer

2. Date of Death (month, day, year)

3. Mailing Address Including ZIP Code of Surviving Spouse or Guardian

4. Nature of Injury Which Caused Death

5. Name of Officer's Former Employing Organization

7. Was Spouse Living With Officer
at Time of Death?

6. Date of Marriage to Officer
CLAIM OF
SURVIVING
SPOUSE

No

Yes

9. Was Spouse Married at Any Time to
Anyone Other Than Officer?
No

Yes

8. Number of Children Now Living
Who Are the Issue of This Marriage

11. Date of Birth of Surviving
Spouse

10. Was the Officer Married at
Any Time to Anyone Else?
No

Yes

If yes to item(s) 9 or 10, submit documents to show dissolution of prior marriages, such as death certificates or divorce decrees.
12. List all Children of the Officer for Whom Claim is Being Made (those living at the time of his death and who were under 18, or who were over 18
and a student or incapable of self-support)
Date of
Living at Address
Name
If Not, Show Mailing Address
Birth
Shown in Item 3?

13. Has a Legal Guardian Been Appointed for Any of the Above-Named Children? of
Guardian of Each Child and Attach a Certified Copy of Appointment Documents

14. List Any Other Relatives Who May be Entitled to Compensation
Name
Date of Birth

Yes

No

Yes

No

Yes

No

Yes

No

If Yes, Give Name and Mailing Address

Relationship
to Officer

Mailing Address

15. Has Application Been Made for Compensation, Annuity, or Other Benefits as a Result of This Death Under Any Compensation Law, Police Death or
Yes
No
If Yes, Give Name and Address of Organization With Which Application Was Filed.
Survivor's Benefit Fund, or Other Such Fund?

16. Was Officer Ever in the Armed
Forces of the United States?
Yes
No

A. Service Number

If Yes, Furnish
17. If Question 16 is Answered ''Yes,'' Has
Application Ever Been Made for Compensation or
Pension on Account of Such Service?
Yes

No

No

C. Period of Service
From
Through

A. Claim Number

B. Name and Address of Office Where Claim is Filed

If Yes, Furnish

18. Has Application Ever Been Made for Any Annuity
on Account of Officer's Civilian Service With the United
States?
Yes

B. Branch of Service

A. Type of Annuity (e.g., civil service retirement)

B. Claim Number

If Yes, Furnish

19. Name of Financial Institution for Depositing Benefits:
20. Account Number:

Checking

Savings

21. Routing or Transit Number:

22. I hereby make claim for compensation for the spouse and/or children listed above, under 5 U.S.C. 8101 et seq., as extended by 5 U.S.C. 8191, as a
result of the death of the above-named officer, who sustained fatal injury while in the performance of duty. Every statement set forth above is true to the
best of my knowledge and belief.

(Signature of Person Filing Claim)

Page 3 of 6

(Date)

Form CA-722b
Rev. Oct. 2022

Claim on Behalf of Dependent Other Than Widow, Dependent Widower, or Children
1. Last, First, Middle Name of Deceased Officer

2. Date of Death (month, day, year)

3. Name of Officer's Former Employing Organization

4. Nature of Injury Which Caused Death

5. Last, First, Middle Name of Dependent
6. Dependent's Mailing Address Including ZIP Code
7. Dependent's Birth Date

11. Amount Contributed by
Officer Toward Dependent's
Support During the 12 Months
Immediately Prior to Death

12. Did Officer Live With Dependent
During the 12 Months Immediately
Prior to Officer's Death?
Yes

13. Was Dependent Employed During
the 12 Months Immediately Prior to
Officer's Death?
Yes

10. Dependency on Officer
Total
Partial

9. Relationship to Officer

8. Dependent's Social Security Number

A. Amount Paid by Officer to
Dependent in Money or Service
for Room and Board in Addition to
Contribution Shown in Item 11.

B. If No Fixed Amount Was Paid for
Room and Board, What is the Fair
Value of Such Room and Board?

No

If Yes, Furnish
A. Occupation (s)

B. Period Employed

C. Monthly Rate of Pay

No

If Yes, Furnish
14. In Addition to Employment, State Other Income From All Sources During the 12 Months Prior to Officer's Death.
From People Other
Investments $
Pensions $
Than Officer $
15. At Time of Officer's Death
Was Dependent Married?
Yes

A. Birth Date

B. Occupation

No

C. Total Income From All Sources
For 12 Months Prior to Officer's
Death

All Other Sources $
D. Monthly Rate of Pay

If Yes, Furnish
16. List All Property Owned by Dependent and/or Spouse (omit clothing, furniture). Give Approximate Market Value of Each Item and Date Acquired

17. List Name and Relationship of Persons Dependent Upon This Dependent.

18. Has Application Been Made for Compensation, Annuity, or Other Benefits as a Result of This Death Under Any Compensation Law, Police Death or
Survivor's Benefit Fund, or Other Such Fund?
Yes
No If Yes, Give Name and Address of Organization With Which Application Was Filed.

19. Was Officer Ever in the Armed
Forces of the United States?
Yes
No

A. Service Number

If Yes, Furnish
20. Has Application Ever Been Made for Any Annuity
on Account of Officer's Civilian Service With the United
States?
Yes

No

B. Branch of Service

C. Period of Service
From
Through

A. Type of Annuity (e.g., civil service retirement)

If Yes, Furnish

21. Name of Financial Institution for Depositing Benefits:
22. Account Number:

B. Claim Number

Checking

Savings

23. Routing or Transit Number:

24. I hereby make claim for compensation under 5 U.S.C. 8101 et seq., as extended by 5 U.S.C. 8191, as a result of the death of the above-named officer,
who sustained fatal injury while in performance of duty. Every statement set forth above is true to the best of my knowledge and belief.

(Signature of Person Filing Claim)

Page 4 of 6

(Date)

Form CA-722c
Rev. Oct. 2022

INSTRUCTIONS FOR COMPLETING THIS FORM
(Please do not detach)
1. GENERAL. This form is used to report a death sustained by a nonFederal law enforcement officer under circumstances involving a crime
against the United States. Specifically, section 8191 of title 5, United
States Code, provides Federal workmen's compensation benefits for a
person determined to have been on any given occasion -

4. CLAIM ON BEHALF OF WIDOW, WIDOWER, OR CHILDREN. This
is a formal claim for death benefits on behalf of all those listed in the
claim, it may be submitted by -

(1) a law enforcement officer and to have been engaged on that
occasion in the apprehension or attempted apprehension of any
person

(2) any guardian, personal representative, or other person legally
authorized to act on behalf of the officer's estate or any of his
survivors; or

(1) any survivor of the deceased officer;

(3) any association of law enforcement officers acting on behalf of
the officer's survivors.

(A) for the commission of a crime against the United States, or
(B) who at that time was sought by a law enforcement authority
of the United States for the commission of a crime against the
United States, or
(C) who at that time was sought as a material witness in a
criminal proceeding instituted by the United States; or
(2) a law enforcement officer and to have been engaged on that
occasion in protecting or guarding a person held for the commission
of a crime against the United States or as a material witness in
connection with such a crime; or
(3) a law enforcement officer and to have been engaged on that
occasion in the lawful prevention of, or lawful attempt to prevent,
the commission of a crime against the United States;

Items 6 through 11 on this claim pertain to the surviving spouse and
should not be completed if no claim is being made on his or her behalf,
or if there is no surviving spouse. Item 12 asks for names of surviving
children. If there are more children than room to enter their names,
attach a separate sheet. This is very important. In the last line of item 12
write, ''see attached sheet for names of additional children.''
In item 14 list anyone else for whom the officer was furnishing some
support at the time of his/her death. Include minor children from his/her
prior marriages even though the officer was not supporting them prior to
his/her death. Again, if more room is needed attach a separate sheet.
The form and the attachments (please read paragraphs 7 and 8 below)
should be sent to the officer's former employing organization.

and to have sustained a personal injury (including disease) resulting in
death, related to that occasion. Federal law enforcement officers are
excluded from section 8191.
If one of the above conditions is met, this form should be filed with the
Office of Workers' Compensation Programs if there are survivors
eligible for benefits or if there are any unpaid medical, funeral, or
transportation bills. The form is designed so that if there are no eligible
survivors who wish to file claim, then their portion of the form may be
detached.

5. CLAIM ON BEHALF OF DEPENDENT OTHER THAN WIDOW
WIDOWER, OR CHILDREN. This is a formal claim for death benefits on
behalf of one person. If more than one person listed below was
dependent on the deceased officer, write to the Office of Workers'
Compensation Programs for extra forms. This claim may be submitted
by (1) any survivor of the deceased officer;
(2) any authorized to act on behalf of the officer's estate or any of his
survivors; or

If additional space is needed for any answer, attach a separate sheet
of paper and write, "see separate sheet," in the appropriate box of this
form. Please place the name of the deceased officer (and case file
number if known) to OWCP within 5 years from the date of death. If
there are no survivors, it is suggested that their portion of this form be
completed before the former employing organization and the physician
complete their portion.
2. EMPLOYING ORGANIZATION'S REPORT. This report must be
completed in every instance by the deceased officer's former
employing organization. Wage information, duty hours, and like
information should be obtained from the organization's records. If the
organization disagrees with one or more of the statements made by
the survivors, it should submit a detailed explanation giving the
reasons for its disagreement.
3. ATTENDING PHYSICIAN'S MEDICAL REPORT. This report is to
be completed by a physician who examined or treated the deceased
officer. It is not necessary if a copy of a more complete medical report
is being submitted.

(3) any association of law enforcement officers acting on behalf of
the officer's survivors. Those dependents other than the widow,
widower, and children who may be eligible for benefits include
dependent parents, dependent grandparents, dependent brothers,
dependent sisters, and dependent grandchildren of the officer. There
is no provision in the law for other relatives.
The form and the attachments (please read paragraphs 7 and 8
below) should be sent to the officer's former employing organization.
6. 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
19 through 21 (CA-722b) or items 21-23 (CA-722c) of these forms. 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.

Page 5 of 6

Form CA-722
Rev. Oct. 2022

(7) As proof of relationship to the officer a grandparent claiming
compensation must provide the birth certificate of the officer's
mother or father, as appropriate; a grandchild claiming
compensation must provide the birth certificate of the officer's son or
daughter, as appropriate;

7. ATTACHMENT. There are several documents that must be
submitted in support of most claims. Sometimes they will not be
readily available. To avoid delays in processing this form, make up a
list of those documents that will be sent at a later date. Then as
documents are received send them directly to the Office of Workers'
Compensation Programs.

(8) A recent medical report describing disability for unmarried
dependents over age 18 who are basing their claim on mental or
physical disability (needed only if claim is being made by widower,
child, brother, sister, or grandchild); if this person is committed to a
public institution merely state the name and address of the institution.

Needed are:
(1) Officer's death certificate (all cases);
(2) Birth certificates of all children claiming compensation; for
adopted children furnish orders of adoption instead of birth
certificates.
(3) Marriage certificate of spouse claiming compensation:
(4) Documents showing dissolution of prior marriages of officer and
of spouse, such as final divorce decrees, death certificates (needed
only if spouse is claiming compensation);
(5) Officer's birth certificate (needed only if claim is being made by
parent, grandparent, brother, or sister of officer);
(6) Dependent's birth certificate (needed only if claim is being made
by brother, sister, or grandchild of officer);

Except for (8), all documents must bear the signature and seal (imprint)
of the public official having custody of such records. All documents or
records originating in a court of law must bear the signature and seal
(imprint) of the proper court official. Photostat copies are not acceptable
unless they bear the actual signature and seal of the public official, not
just a copy.
8. SUBMITTING THIS FORM. This form and available attachments
should be turned over to the officer's former employing organization.
The organization will have any remaining parts completed. Afterwards, it
should review the form and attachments for completeness and to see
that all signatures appear. If a report of investigation of any type was
made on the death or the incident leading to death, a copy should be
attached. When the form and any statements and attachments are
ready for transmission, this instruction page should be removed. Only
one copy of this form (the original) need be submitted.

Privacy Act
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 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) 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.
We are authorized to request a taxpayer identification number (TIN) or Social Security Number (SSN) under the Debt Collection Improvement Act of 1996, Title
31 U.S.C. amended section 7701(c) (1), which mandates us to require regulated entities and persons who are doing business with a Federal agency to furnish
a TIN or SSN. The SSN 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.
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 this information is estimated to average 90 minutes per response, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the date needed, and completing and reviewing the collection of information.
The authority for requesting this information is 5 U.S.C. 8101 et seq. The information will be used to determine entitlement to benefits. Furnishing the requested
information is required for the claimant to obtain or retain a benefit. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the U. S. Department of Labor, OWCP, Room S3229, 200 Constitution Avenue, NW,
Washington, DC 20210, and reference OMB Control Number 1240-0022. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS.
All completed forms should be sent to
Office of Workers' Compensation Programs
Division of Federal Employees'
Longshore and Harbor Workers' Compensation
Federal Employees' Compensation Act, (OWCP/DFELHWC-FECA)
400 W. Bay Street Suite 722
Jacksonville, FL 32202
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 in the form of communication assistance, accommodation(s) and/or
modification(s) 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 accommodate your disability. Please contact our office or your OWCP claims
examiner to ask about this assistance.

Page 6 of 6

Form CA-722
Rev. Oct. 2022