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Form CA-41 "Claim for Survivor Benefits Under the Federal Employees' Compensation Act 8102a" Form CA-41 is to be completed by the employee's survivor(s) who wish to claim all or a portion of the death gratuity. Each individual survivor must complete a separate claim. Form(s) should be submitted to OWCP. Deceased Employee Information This section must be completely filled out with the full name, sex, social security number, date of birth, date of death and employer on date of death of the deceased employee. Survivor Information The individual survivor claiming any or all of the death gratuity must completely fill out this section with his/her full name, sex, social security number, date of birth, relationship to the decedent, complete address and telephone number. Injury/Occupational Illness Information If there was a claim filed for injury prior to the date of the employee's death , the claim number and employer information should be completed. The survivor should identify the armed force conducting the contingency operation, the place where the injury or exposure occurred, and a description of the injury /exposure which led to the employee's death. Other Death Gratuity Benefits Paid The survivor must list any death gratuity benefits already paid under any other law of the United States for this death. The information should identify the agency that paid the gratuity, complete address, telephone number, claim number and the amount paid. Other Potential Survivors In this section, the applicant should indicate whether, to his/her knowledge, the employee completed a CA-40 prior to death , and if so provide a copy of the form. Especially important, he/she must also indicate whether there are any other persons that may qualify as survivors. Survivor Declaration The claimant must sign and date the form. |