INSTRUCTION TO BENEFICIARIES 

1. It is important that you carefully complete the other side of this form and return it to the OWCP within 30 days. Your failure to do so will result in 

suspension of the compensation you are receiving. 

2. Complete Section A by printing the full name of the deceased employee and the OFFICE OF WORKERS' COMPENSATION PROGRAMS file 

number. 

3. Answer all questions in the section or sections that apply to you. If you are receiving compensation as the: 

(A) SURVIVING SPOUSE - Complete Section B. 

(B) SURVIVING SPOUSE RECEIVING COMPENSATION ON HER OR HIS ACCOUNT AND ON ACCOUNT OF A MINOR CHILD OR CHILDREN - 

Complete Sections B and C. 

(C) GUARDIAN OR CUSTODIAN OF A MINOR CHILD OR GRANDCHILD OR A PERSON INCAPABLE OF SELF-SUPPORT - Complete Section C. 

(D) PARENT, GRANDPARENT, OR A PERSON WHO IS PHYSICALLY INCAPABLE OF SELF-SUPPORT - Complete Section D. 

4. Carefully read and comply with directions in Section E. 

5. Complete and sign the certificate in Section F. 

6. Please return the completed form, in an envelope, to the address shown below.

Claim for Continuance of Compensation 

Under the Federal Employees' 

Compensation Act

U.S. Department of Labor 

Office of Workers' Compensation Programs

OMB No. 1240-0015 

Expires: 01/31/2027

The information on this form will be used to determine your eligibility for continuing benefits. Your response to this information is required to 

retain your compensation benefits. Your benefits may be suspended if you fail to return this form within 30 days of the date of the request. (20 CFR 

10.414)

RETURN TO: OWCP/DFELHWC-FECA 

PO Box 8311 

London, KY 40742-8311 

(202) 513-6860 

OR 

You can electronically upload documents into your case using the Employees’ Compensation Operations and Management Portal (ECOMP). 

You can access ECOMP from any internet browser at: https://www.ecomp.dol.gov/ . When you access the website, choose the "Upload 

Document" option. You will be asked to provide your case number, last name, date of birth and date of injury to upload a document. ECOMP 

will then provide you with a Tracking Number so that you can verify when OWCP has received your document. For more detailed 

information about this document submission feature, visit the ECOMP website and click "Help."

Privacy Act 

The Privacy Act of 1974 as amended, (5 U.S.C. 552a), and the Federal Employees’ Compensation Act, as amended and extended (5 U.S.C 8101, et. 

seq) authorizes collection of this information. The information will be used to determine continuing entitlement to benefits. Furnishing the requested 

information is required for a claimant to obtain or retain a benefit. Failure to provide the information may result in the delay of a claim or payment of 

benefits, or may result in an unfavorable decision or reduced levels of benefits. Additional disclosures of this information made: (1) to determine 

eligibility for and the amount of benefits payable under the FECA, and may be verified through computer matches or other appropriate means; (2) 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; (3) to other Federal agencies, other government 

entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services; (4) to physicians and 

other healthcare providers for use in providing treatment or medical/vocational rehabilitation, making evaluations for the Office, and for other purposes 

related to the medical management of the claim; and (5) 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. 

Public Burden Statement 

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Public reporting burden for 

this collection of information is estimated to average 5 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. If you have any comments regarding this 

estimate or any other aspect of this information collection, including suggestions for reducing this burden, please send them to the Department of Labor, 

Office of Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, N.W. Washington, D.C. 20210. DO NOT SEND THE 

COMPLETED FORM TO THIS OFFICE..

CA-12 

(Rev. 10-17)

Accommodation Statement 

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.
IMPORTANT: READ CAREFULLY THE INSTRUCTIONS ON THE OTHER SIDE OF THIS FORM BEFORE ANSWERING 

 THE QUESTIONS BELOW

I HEREBY APPLY FOR CONTINUANCE OF COMPENSATION BENEFITS AWARDED TO ME (OR TO THE CLAIMANT ON WHOSE BEHALF I AM ACTING) BY 

THE OFFICE OF WORKERS' COMPENSATION (OWCP) ON ACCOUNT OF THE DEATH OF:

A. Name of Deceased Employee Employee's Federal Retirement Plan OWCP File No.

CSRS FERS Other

THIS BLOCK TO BE COMPLETED BY SURVIVING SPOUSE RECEIVING COMPENSATION

B. 1. Name Social Security Number

 2. Have You Married since the Death of Above Named Employee? (If "Yes" 

complete 13)

Yes No

 3. Do You Receive a Benefit, Pension or Allowance from any other Federal Agency such as the (If "Yes" 

 Veterans' Administration, Social Security Administration or the Office of Personnel Management complete 14) 

 on Account of the Death of this Employee?

Yes No

THIS BLOCK TO BE COMPLETED BY ANY PERSON RECEIVING COMPENSATION ON BEHALF OF CHILD 

GRANDCHILD, OR DEPENDENT INCAPABLE OF SELF-SUPPORT

C. 4. Name Social Security Number

 5. Have any Dependents receiving compensation married, turned 18, or left school (If "Yes" 

 if over 18 since the Death of the Above Named Employee? complete 13)

Yes No

 6. Do Any Dependents You Claim Compensation for Receive a Benefit, Pension or Allowance from (If "Yes" 

 Any Other Federal Agency such as the Veterans' Administration, Social Security complete 14) 

 Administration, or the Office or Personnel Management on Account of the Death of this Employee?

Yes No

 7. Give the Following Information for Each Person You Receive Compensation for or are Aware may be Receiving Compensation on Account of the 

Employee’s Death:

 NAME SOCIAL 

SECURITY 

NUMBER

AGE IS PERSON IN 

YOUR CUSTODY? 

(Yes or No)

NAME, ADDRESS, AND RELATIONSHIP OF 

PERSON(S) HAVING CUSTODY IF NOT IN 

YOUR CUSTODY

THIS BLOCK IS TO BE COMPLETED BY PARENT, GRANDPARENT, GUARDIAN OR DEPENDENT PHYSICALLY INCAPABLE OF SELF-SUPPORT

D. 8. Name Social Security Number

 9. Have You Married since the Death of Above Named Employee? (If "Yes" 

complete 13)

Yes No

 10. Do You Receive a Benefit, Pension or Allowance from any other Federal Agency such as the (If "Yes" 

 Veterans' Administration, Social Security Administration or the Office of Personnel Management complete 14) 

 on Account of the Death of this Employee?

Yes No

 11. Are You Capable of Self-Support? Yes No

 12. Have You Been Employed Since Filing Your Last Claim Form? (If "Yes" 

complete 15)

Yes No

CA-12 

(Rev. 10-17) 

PAGE 2 
ADDITIONAL INFORMATION: THIS BLOCK TO BE COMPLETED ONLY WHEN AN ANSWER TO 2, 3, 5, 6, 9, 10 or 12 IS "YES."

E. 13. When and Where was the Marriage Performed and What was the Change in Name, If Any? HOW OLD WERE YOU AT THE TIME OF 

MARRIAGE?

 14. What Agency is Paying the Benefits and For What Reason Are They Being Paid?

 15.State the Name of Your Employer, Nature of Employment, Dates Employed, and Amount Earned.

BENEFICIARY'S CERTIFICATION - TO BE COMPLETED IN ALL INSTANCES

F. I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND 

THAT I WILL IMMEDIATELY NOTIFY THE OFFICE OF WORKERS’ COMPENSATION PROGRAMS OF ANY CHANGES IN STATUS. 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.

 Signature of Beneficiary (or guardian) Date (month, day, year)

 Address of Beneficiary (or guardian) Telephone Where You Can Be Reached

 Name of Witness if Beneficiary Signs by Mark (X) Telephone Number of Witness

 Signature of Witness Date Witnessed

CA-12 

 (Rev. 10-17) 

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