Ca5 Claim For Compensation By Widow Widower And Or Children Page 4

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DEATH BENEFITS FOR SURVIVING WIDOW, WIDOWER AND/OR CHILDREN

UNDER THE FEDERAL EMPLOYEES' COMPENSATION ACT (FECA)

To quality for benefits, a widow or widower must have been living with the employee or

Widow or

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

Widower

remarriage. Upon remarriage, a widow or widower will receive a lump sum equal to 24 times his

or her monthly compensation. If the remarriage occurs at age 60 or later, no lump sum is paid.

Instead, payments continue for life.

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

Children

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.

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

Compensation

eligible children - 45% if there are eligible children.

Rates

Children - 15% each, not to exceed a total of 30%, shared equally if there is a widow or

widower; if there is no widow or widower, 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.

Federal payments are made through Direct Deposit. Therefore, a, completed Form SF-1199A,

Direct Deposit Sign-up must be submitted with Form CA-5.

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,

Allowance

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.

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.

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 Worker' 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 also be given 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. (5) Information may be disclosed to physicians and other health

care 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. (6) 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. (7) Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. 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. (8) 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.

Note: This notice applies to all forms requesting information that you might receive from the Office in connection with the

processing and adjudication of the claim you filled under the FECA.

Public Burden Statement

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

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

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

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

For sale by the Superintendent of Documents, U.S. Government Printing Office

Washington D.C. 20402

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