Ca5 Claim For Compensation By Widow Widower And Or Children
Download a blank fillable Ca5 Claim For Compensation By Widow Widower And Or Children in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Ca5 Claim For Compensation By Widow Widower And Or Children with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Reset
Print
Claim for Compensation by Widow,
U.S. Department of Labor
Office of Workers' Compensation Programs
Widower, and/or Children
OMB No. 1240-0013
Expires: 07-31-2013
1. Name of deceased employee (Last, first, middle)
2. Date of Birth
4. Date of Death
5. Social Security Number
3. Date of Injury
(Mo., day, year)
(Mo., day, year)
(Mo., day, year)
7. Nature of injury which caused death
6. Name and address of employing agency (Include ZIP Code)
Claim of Surviving Husband or Wife (Items 8 through 13)
8. Name and address (Include ZIP Code)
10.
9.
Your Date of Birth
Date of Marriage to Employee
(Mo., day, year)
(Mo., day, year)
Were you ever married to anyone other
13.
Was employee ever married to
11.
Were you living with the employee
12.
than the employee?
at time of death?
anyone other than yourself?
Yes
Yes
No
Yes
No
No
List all of employee's children from this marriage who may be entitled to compensation (See attached information sheet for
14.
definition of children)
Relationship
Date of Birth
Address (Include ZIP Code)
Name
14a. List all of employee's children from prior marriages who may be entitled to compensation:
Address (Include ZIP Code)
Name
Relationship
Date of Birth
15. If a legal guardian has been appointed for any child named above, give name of child, name and address of the guardian.
Child
Guardian's Address (Include ZIP Code)
Guardian
16. List other relatives who were fully or partially dependent on employee:
Name
Relationship
Date of Birth
Address (Include ZIP Code)
17.
If application has been made for any other Federal Retirement or
18.
If application has been made for Veterans Administration (VA)
Disability Law because of employee's death, give:
benefits because of employee's death, give:
Service number:
VA Claim number:
CSRS
FERS
SSA
Other
Retirement System
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
19.
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
21.
Amount of burial expense
22.
Name and address of party (other than VA) whose funds were used to pay burial
paid or payable by VA
expense and amount paid:
$
$
$
I hereby certify that each and every statement made above Is true to the best of my knowledge.
23. Signature of person filing claim
24. Address (Include ZIP Code)
25. Date
(Mo., day, year)
Previous edition usable
Form CA-5
Rev. 03-01-2010
ADVERTISEMENT
0 votes
Related Articles
Related forms
Va Form 21-0966 - Intent To File A Claim For Compensation And/or Pension, Or Survivors Pension And/or Dic
Legal
Va Form 21-0966 - Intent To File A Claim For Compensation And/or Pension, Or Survivors Pension And/or Dic
Legal
Va Form 21-0966 - Intent To File A Claim For Compensation And/or Pension, Or Survivors Pension And/or Dic
Legal
Va Form 21-534a - Application For Dependency And Indemnity Compensation By A Surviving Spouse Or Child - In-service Death Only
Legal
Va Form 21-534a - Application For Dependency And Indemnity Compensation By A Surviving Spouse Or Child
Legal
Form Ca-2 - Notice Of Occupational Disease And Claim For Compensation - United States Department Of Labor, Office Of Workers Compensation Programs
Legal
Related Categories
Parent category: Legal