§ 177.105 Administrative claim; evidence and information to be submitted. ( a ) *Death.* In support of a claim based on death, the claimant may be required to submit the following evidence or information: ( 1 ) An authenticated death certificate or other competent evidence showing cause of death, date of death, and age of the decedent.
( 2 ) Decedent's employment or occupation at time of death, including his or her monthly or yearly salary or earnings (if any), and the duration of his or her last employment or occupation.
( 3 ) Full names, addresses, birth date, kinship, and marital status of the decedent's survivors, including identification of those survivors who were dependent for support from the decedent at the time of death.
( 4 ) Degree of support afforded by the decedent to each survivor dependent on him or her for support at the time of death.
( 5 ) Decedent's general physical and mental condition before death.
( 6 ) Itemized bills for medical and burial expenses incurred by reason of the incident causing death, or itemized receipts of payment for such expenses.
( 7 ) If damages for pain and suffering before death are claimed, a physician's detailed statement specifying the injuries suffered, duration of pain and suffering, any drugs administered for pain, and the decedent's physical condition in the interval between injuries and death.
( 8 ) Any other evidence or information which may have a bearing on either the responsibility of the United States for the death or the amount of damages claimed.
( b ) *Personal injury.* In support of a claim for personal injury, including pain and suffering, the claimant may be required to submit the following evidence or information: ( 1 ) A written report by the attending physician or dentist setting forth the nature and extent of the injury, nature and extent of treatment, any degree of temporary or permanent disability, the prognosis, period of hospitalization, and any diminished earning capacity. In addition, the claimant may be required to submit to a physical or mental examination by a physician employed by OPM or another Federal agency. On written request, OPM will make available to the claimant a copy of the report of the examining physician employed by the United States, provided the claimant has furnished OPM with the report referred to in the first sentence of this subparagraph. In addition, the claimant must have made or agrees to make available to OPM all other physician's reports previously or thereafter made of the physical or mental condition that is the subject matter of his or her claim.
( 2 ) Itemized bills for medical, dental, and hospital expenses incurred, or itemized receipts of payment for such expenses.
( 3 ) If the prognosis reveals the necessity for future treatment, a statement of expected expenses for such treatment.
( 4 ) If a claim is made for loss of time from employment, a written statement from his or her employer showing actual time lost from employment, whether he or she is a full-or part-time employee, and wages or salary actually lost.
( 5 ) If a claim is made for loss of income and the claimant is self-employed, documentary evidence showing the amount of earnings actually lost.
( 6 ) Any other evidence or information which may have a bearing on either the responsibility of the United States for the personal injury or the damages claimed.
( c ) *Property damage.* In support of a claim for injury to or loss of property, real or personal, the claimant may be required to submit the following evidence or information: ( 1 ) Proof of ownership of the property.
( 2 ) A detailed statement of the amount claimed with respect to each item of property.
( 3 ) An itemized receipt of payment for necessary repairs or itemized written estimates of the cost of such repairs.
( 4 ) A statement listing date of purchase, purchase price, and salvage value, where repair is economical.
( 5 ) Any other evidence or information which may have a bearing on either the responsibility of the United States for the injury to or loss of property or the damages claimed.