24. Account number:

Claim for Compensation by

Surviving Spouse and/or Children

OMB No. 1240-0013

Expires: 06/30/2026

1. Name of deceased employee 2. Date of Birth 3. Date of Injury 4. Date of Death 5. Social Security Number

(Mo., day, year) (Mo., day, year) (Mo., day, year)

6. Name and address of employing agency (Include ZIP Code) 7. Nature of injury which caused death

Claim of Surviving Spouse (Items 8 through 13)

Your Date of Birth

(Mo., day, year)

Date of Marriage to Employee

(Mo., day, year)

8. Name and address (Include ZIP Code)

Was employee ever married to

anyone other than yourself?

Were you ever married to anyone other

than the employee?

Were you living with the employee

at time of death? Yes No Yes No Yes No

List all of employee's children from this marriage who may be entitled to compensation (See attached information sheet for

definition of children)

14a. List all of employee's children from prior marriages who may be entitled to compensation:

15. If a legal guardian has been appointed for any child named above, give name of child, name and address of the guardian.

Guardian

16. List other relatives who were fully or partially dependent on employee:

If application has been made for any other Federal Retirement or

Disability Law because of employee's death, give:

If application has been made for Veterans Administration (VA)

benefits because of employee's death, give:

Retirement System CSRS FERS SSA Other Service number: VA Claim number:

Address of VA office where claim is filed:

a. Claim Number for each claim:

b. If a claim has been made against a third party because of employee's

death, give: a. Date each benefit began: Amount of recovery: b.

 Name and address of third party: a. Amount of each benefit paid per month: $

b.

20. Total burial expense Amount of burial expense

paid or payable by VA

Name and address of party (other than VA) whose funds were used to pay burial

expense and amount paid:

$ $ $

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 the FECA, 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.

26. Signature of person filing claim 27. Address (Include ZIP Code) 28. Date (Mo., day, year)

Form CA-5 (Rev. 10-2020)

U.S. Department of Labor

Office of Workers' Compensation Programs

Child Guardian's Address (Include ZIP Code)

11. 12. 13.

17. 18.

19.

21. 22.

9. 10.

$

14.

Name Relationship Date of Birth Address (Include ZIP Code)

Name Relationship Date of Birth Address (Include ZIP Code)

Name Relationship Date of Birth Address (Include ZIP Code)

Checking Savings

25. Routing or transit number:

23. Name of Financial Institution for Depositing Benefits:

(Last, first, middle)

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.
Attending Physician's Report

1. Name of deceased employee (Last, first, middle) 2. Date of death (Mo., day, year)

3. What history of injury or employment related disease was given to you? 4. If treated for disease, give diagnosis.

6. Show dates on which treatment

was given.

5. If death was not instantaneous, describe the treatment you provided.

7. What was the direct cause of death?

8. What were the contributory causes of death, if any?

In your opinion, was the death of the employee due to the injury or employment related disease as reported in item 3 above?

Give the medical reasons for your opinion, unless causal relationship is obvious. Yes No

Was a biopsy or an autopsy performed?

Arrange for a copy of the report to be submitted. Yes No

11. Name, specialty, and address of physician (Please type - include ZIP Code)

I certify that the statements in response to the questions asked above are true, complete, and correct to the best of my knowledge. Further, I 

understand that any false or misleading statements or any misrepresentation or concealment of material fact which is knowingly made may 

subject me to criminal prosecution.

12. Signature 13. Date signed (Mo., day, year)

9.

10.

Form CA-5 PAGE 2 (Rev. 10-2020)
INSTRUCTIONS FOR COMPLETING FORM CA-5, CLAIM FOR COMPENSATION 

BY SURVIVING SPOUSE AND/OR CHILDREN

Who Should This claim form should be completed and filed by the surviving spouse for self and

surviving children. If there is no surviving spouse, the children's guardian

completes the claim.

File Claim

When Should Claim must be filed within three years following date of death, unless the decedent's

immediate superior had actual knowledge of an on-the-job injury or death within 30

days; or written notice of the injury or death was given within 30 days. The timely filing

of a disability claim will satisfy the time requirements for a death claim based on the

same injury.

Claim Be Filed

What Documents The marriage certificate(s) for a surviving spouse; death certificate for decedent if not

Are Required previously submitted; birth certificate or adoption documents for each child. Also, if

appropriate, Letter of Guardianship. If either the decedent or the surviving spouse was

previously married, legal documents showing dissolution of such prior marriage(s).

Copies of certificates or documents are acceptable only if they are certified by the

person having official custody of such records. They should then be attached to the

claim form when it is filed.

How to

Complete Claim

All items should be completed. If an item is not applicable, indicate by showing "NA".

Note that the form requests information about several different categories of persons,

i.e., items 1-7 make inquiry about the decedent; 8-13 the surviving spouse;

14-14a, surviving children; and 15, the children's guardian. The attending physician's

report on the reverse of the claim must also be completed before the form is submitted to

the OWCP.

Funeral/Burial Submit original itemized funeral and burial bills. If paid, so indicate and give name and

address of person making payment. If an Administrator or Executor has been

appointed, give such person's name and address and attach a copy of the appointment

document.

Allowance

See the following page for a definition of dependents and a description of benefits.

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Form CA-5 PAGE 3 (Rev. 10-2020)

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/or modification(s) to aid you in the FECA 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.
DEATH BENEFITS FOR SURVIVING SPOUSE AND/OR CHILDREN 

UNDER THE FEDERAL EMPLOYEES' COMPENSATION ACT (FECA)

To qualify for benefits, a surviving spouse must have been living with the employee or 

separated for reasonable cause prior to the time of death. Payments continue for life or until 

remarriage before age 55. Upon remarriage before age 55, a surviving spouse will receive a 

lump sum equal to 24 times his or her monthly compensation. If the remarriage occurs at age 

55 or later, no lump sum is paid. Instead, payments continue for life.

Surviving 

Spouse

Eligible children include natural, adopted, step and posthumous children unmarried and

under 18 years of age. Payments continue beyond 18 if the child is incapable of

self-support because of mental or physical incapacity. Payments also continue on behalf

of children over 18 if they are full-time students. Student benefits terminate on: marriage,

completion of four years of education beyond high school level, or at age 23, whichever

occurs first.

Children

For surviving spouses - 50% of the employee's monthly pay if there are no surviving

eligible children - 45% if there are eligible children.

Compensation

Rates

Children - 15% each, not to exceed a total of 30%, shared equally if there is a surviving spouse;

if there is no surviving spouse, 40% for one child plus 15% for each additional child,

shared equally. Monthly payments for all beneficiaries cannot exceed 75% of the employee's

monthly pay rate, or 75% of the top step of GS-15 of the General Schedule.

If the employee was covered under the Federal Employees' Retirement System (FERS), 5

USC 8116(d)(2) requires that Social Security benefits payable to beneficiaries, which are

attributable to the deceased employee's Federal Service, are deducted from the

beneficiary's compensation entitlement.

Funeral/Burial Funeral and burial expenses up to a maximum of $800 may be paid. Amount paid by the

VA will be deducted. If death occurs away from the employee's duty station,

transportation costs may be paid to return the deceased employee to his home or last

place of residence. In addition to any funeral or burial expenses, a sum of $200 may be

paid for reimbursement of the costs of termination of the decedent's status as an

employee of the United States.

Allowance

Third Party If the injury or death results from activity of a person or party other than the Federal

Action Government, a "third party action" or lawsuit may be indicated. In such instances the

Department of Labor will provide further instructions.

If additional information is needed, it may be obtained from the Office of Workers' Compensation Programs.

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• Information

Direct Deposit 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 23 through 25 of this form. 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.

•

Form CA-5 PAGE 4 (Rev. 10-2020)

Benefits 

Social Security
Privacy Act Notice

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. 

Form CA-5 PAGE 5 (Rev. 10-2020)

Public Burden Statement

Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

Public reporting burden for this collection of information is estimated to average 90 minutes per response, including time for reviewing instructions, 

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation 

to respond to this collection is required to obtain or retain a benefit (5 U.S.C. 8101 et seq.). Send comments regarding this burden estimate or any other 

Department of Labor, Room S-3229, 200 Constitution Avenue, N.W., Washington, D.C. 20210, and reference the OMB Control Number 1240-0013. 

aspect of this collection of information, including suggestions for reducing this burden, to the Office of Workers' Compensation Programs, U.S.