U.S. DEPARTMENT OF LABOR 

Office of Workers’ Compensation Programs 

Division of Federal Employees' Compensation

OMB Number: 1240-0017 

Expiration Date: 06/30/2026

Male Female

Deceased Employee Information

Official Notice of Employees' Death for Purposes of FECA Section 8102a Death Gratuity 

(CA-42) 

Instructions on Completing Form CA-42. Complete each item as completely as possible and include a copy of the death certificate and 

a copy of the most recent CA-40 beneficiary designation. Please sign and date the form noted on page 3 and forward it to Office of 

Workers' Compensation Programs' Division of Federal Employees' Compensation. 

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 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.

1. Name (Last, First, Middle):

2. Sex: 3. Social Security Number:

4. Date of Birth (DOB): 5. Date of Death (DOD):

6. Employing agency:

7. Employee’s position with the agency:

Circumstances of the Employees’ Injury/Death

8. Date and hour of injury:

9. Location where the injury occurred:

10. Date that the employee’s immediate supervisor first had knowledge of the injury:

11. Describe how the injury occurred:

12. Was the employee in the performance of duty when the injury occurred? Yes No

13. What were the employee’s assigned duties at the time of death?

CA-42 PAGE 1 (Rev. 05-16)

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. 
Circumstances of the Employees’ Injury/Death (Cont’d)

14. Were the employee’s duties being performed in connection with an Armed Force contingency operation?

Yes No

If yes, please indicate which Armed Force and what operation.

Include a copy of the employee’s death certificate with this form.

Survivor Information

15. Did the employee complete a Designation of a Recipient of the Death Gratuity Payment (CA-40) or otherwise 

indicate, in writing, a designation? Yes No

If yes, provide a copy of the form CA-40 or other pertinent written documentation. 

Include any completed CA-41 forms the employee’s agency received from survivors or alternate beneficiaries.

16. Did the employee have any living survivors or alternate beneficiaries? 

Please list all potential beneficiaries.

Yes No

Name Relationship to 

decedent

Address

Phone Number(s)

CA-42 PAGE 2 (Rev. 05-16)
Other Death Gratuity Benefits Paid

17. 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:

Employing Agency Certification

As a representative of the employing agency, I hereby certify that the information provided above concerning coverage of 

the employee under section 8102a of the Federal Employees’ Compensation Act is true and accurate to the best of my 

knowledge and belief. 

 

Signature of Agency Official: Date:

Official Name:

Official Title:: 

Address:

Phone:

CA-42 PAGE 3 (Rev. 05-16)
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.

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 number. Public reporting burden for this collection of information is estimated to average 20 

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: Do not submit the completed claim form to this address. Completed notices are to be submitted to the appropriate 

district office of the Office of Workers’ Compensation Programs.

Privacy Act Statement

Public Burden Statement

CA-42 PAGE 4 (Rev. 05-16)