OMB No. 1240-0022 

Expires: 10/31/2026 

Notice of Law Enforcement Officer's 

Death

U.S. Department of Labor 

Office of Workers' Compensation Programs

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

control number.

EMPLOYING ORGANIZATION'S REPORT

1. Name and Mailing Address Including ZIP Code of 

Employing Organization

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 9. Date of Death 10. Date and Hour Pay Stopped

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

Base $ Per

Per $ Per

$

Subsistence, If Extra $

Quarters, If Extra $ Per Per

15. Circle Days Normally Worked 

Per Week (exclusive of overtime)

14. Number of Hours Worked 

Per Day (exclusive of overtime)

13. On Day of Injury a. Began b. Ended

Officer's Shift

16. Did Officer Work for the Organization a Full 11 

Months Immediately Prior to Injury?

17. If No, Would His Job Have Afforded Employment For 

11 Months Except For the Injury?

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?

b. Officer's intoxication?

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

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?

If Yes, Give Name and Address of Organization With Which Application Was Filed.

2. Name of Deceased Officer's Immediate Superior

3. Name and Telephone Number of Person to Contact

Page 1 of 6

AM

PM

AM

PM

AM

PM

AM

PM

SU MO TU WE TH FR SA

Yes No Yes No

Yes No

Yes No

Yes No

Yes No

Form CA-722a 

Rev. Oct. 2022

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.
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 26. Date Signed

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.

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

1. Last, First, Middle Name of Deceased Officer 2. Date of Death (month, day, year)

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? Yes No If No, State

Your Reasons For Believing Death Resulted From Other Causes.

9. Was a Biopsy or Autopsy Performed? Yes No If So, By Whom?

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

11. Signature 12. Date Signed

13. Mailing Address Including ZIP Code

Page 2 of 6

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 

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

8. Number of Children Now Living 

Who Are the Issue of This Marriage

7. Was Spouse Living With Officer 

at Time of Death?

6. Date of Marriage to Officer

CLAIM OF 

SURVIVING 

SPOUSE

Yes No

11. Date of Birth of Surviving 

Spouse

10. Was the Officer Married at 

Any Time to Anyone Else?

9. Was Spouse Married at Any Time to 

Anyone Other Than Officer?

Yes No Yes No

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) Living at Address 

Shown in Item 3? If Not, Show Mailing Address

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

Yes No If Yes, Give Name and Mailing Address

14. List Any Other Relatives Who May be Entitled to Compensation Relationship 

to Officer

15. 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.

16. Was Officer Ever in the Armed A. Service Number B. Branch of Service C. Period of Service

Forces of the United States? From

Yes No Through If Yes, Furnish

17. If Question 16 is Answered ''Yes,'' Has 

Application Ever Been Made for Compensation or 

Pension on Account of Such Service?

A. Claim Number B. Name and Address of Office Where Claim is Filed

Yes No If Yes, Furnish

18. Has Application Ever Been Made for Any Annuity 

on Account of Officer's Civilian Service With the United 

States?

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

Yes No If Yes, Furnish

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) (Date)

Name

Date of 

Birth

Name Date of Birth Mailing Address

Page 3 of 6

Yes No

Yes No

Yes No

20. Account Number: 21. Routing or Transit Number:

19. Name of Financial Institution for Depositing Benefits: Checking Savings

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

8. Dependent's Social Security Number 9. Relationship to Officer 10. Dependency on Officer

Total Partial

B. If No Fixed Amount Was Paid for 

Room and Board, What is the Fair 

Value of Such Room and Board?

A. Amount Paid by Officer to 

Dependent in Money or Service 

for Room and Board in Addition to 

Contribution Shown in Item 11.

12. Did Officer Live With Dependent 

During the 12 Months Immediately 

Prior to Officer's Death?

11. Amount Contributed by 

Officer Toward Dependent's 

Support During the 12 Months 

Immediately Prior to Death

Yes No

If Yes, Furnish

13. Was Dependent Employed During 

the 12 Months Immediately Prior to 

Officer's Death?

A. Occupation (s) B. Period Employed C. Monthly Rate of Pay

Yes 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 $ All Other Sources $

C. Total Income From All Sources 

For 12 Months Prior to Officer's 

Death

15. At Time of Officer's Death B. Occupation D. Monthly Rate of Pay

Was Dependent Married?

A. Birth Date

Yes No

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 A. Service Number B. Branch of Service C. Period of Service

Forces of the United States? From

Yes No

Through If Yes, Furnish

20. Has Application Ever Been Made for Any Annuity B. Claim Number

on Account of Officer's Civilian Service With the United 

States?

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

Yes No If Yes, Furnish

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) (Date)

Page 4 of 6

22. Account Number: 23. Routing or Transit Number:

21. Name of Financial Institution for Depositing Benefits: Checking Savings

Form CA-722c 

Rev. Oct. 2022
INSTRUCTIONS FOR COMPLETING THIS FORM

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) any survivor of the deceased officer; 

(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 

(3) any association of law enforcement officers acting on behalf of 

the officer's survivors. 

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. 

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 

(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.

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 - 

(1) a law enforcement officer and to have been engaged on that 

occasion in the apprehension or attempted apprehension of any 

person 

(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; 

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. 

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. 

(Please do not detach)

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; 

(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.

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.

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. 

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); 

Page 6 of 6

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, documents, and inquiries 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) 

PO Box 8311 

London, KY 4072-8311 

 

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.

Form CA-722 

Rev. Oct. 2022