CA-40 / CA-41 / CA-42

The Office of Workers’ Compensation Programs (OWCP) website includes three forms pertaining to the Death Gratuity.

These forms were created as a result of Section 1105 NDAA FY 08, P.L. 110-181, enacted January 28, 2008 and are located at http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm. They are:

CA-40 – Designation of a Recipient of the Federal Employees’ Compensation Act Death Gratuity Payment under Section 1105 of Public Law 110-181 (Section 8102a)

CA 41 – Claim for Survivor Benefits Under the Federal Employees’ Compensation Act Section 8102a Death Gratuity

CA 42 – Official Notice of Employees’ Death for Purposes of FECA Section 8102a Death Gratuity

Regulations (http://edocket.access.gpo.gov/2009/pdf/E9-18523.pdf) were published and effective August 18, 2009. This law amended the Federal Employees’ Compensation Act (FECA) by creating section 8102a. Section 8102a establishes a new FECA benefit for eligible survivors of Federal employees and Non-Appropriated Fund Instrumentality (NAFI) employees who die of injuries incurred in connection with service of an Armed Force in a contingency operation. A retroactive provision also applies to survivors of employees who died on or after October 7, 2001 due to injuries incurred in connection with the service of an Armed Force in the theater of Operation Enduring Freedom and Operation Iraqi Freedom. The benefit will pay a death gratuity of $100,000 (minus applicable offsets) to those survivors eligible.

The regulations provide agency responsibilities which are summarized below. For detailed guidance, please refer to the link above (20 CFR 10.914).

The agency is responsible for counseling employees prior to deployment and, if circumstances occur, they must also counsel survivors who may be eligible for the death gratuity benefit.

Agencies must:

- Maintain all designations (CA-40) completed by the employee. The forms must be signed by the employee and by a representative of the agency. The designations must be filed in the Official Personnel Folder (OPF) or a related system of records. The designation(s) must be forwarded to OWCP with the CA-42 upon receiving notification of the death of an employee due to injuries incurred in connection with a contingency operation.

- Complete form CA-42 immediately upon learning of an employee’s death that qualifies for the death gratuity, or upon receiving notification from OWCP that a survivor has submitted a claim. Include a copy of the death certificate and a copy of the most recent CA-40 (as noted above).

- Forward all CA-41s received by the survivors to OWCP-Cleveland District Office, 1240 East Ninth Street, Rm. 851, Cleveland, OH 44199.

- Make a determination of whether an illegitimate child of a deceased male employee has provided sufficient evidence to show they qualify for the death benefit. Typically, OWCP will make this determination; however, if they are unable to make a determination of whether the child is eligible, the agency will be notified and is responsible for evaluating the evidence, making the final decision, and notifying OWCP immediately of the determination.

- Notify OWCP of any additional death gratuity payments under any other law for which the employee’s death qualifies, such as, the $10,000 death gratuity to the personal representative of civilian employees, Title VI, Section 651 of the Omnibus Consolidated Appropriations Act of 1996 (P.L. 104-208, September 30, 1996) or the death gratuity payable under P.L. 109-234, which authorizes DOD to pay beneficiaries a benefit equivalent to one year’s salary for deaths occurring during official duty in Iraq or Afghanistan during fiscal years 2006 - 2008. Certain death gratuity payments will offset the death gratuity payable under P.L. 110-181.

Department of Defense
Defense Civilian Personnel Advisory Service
HR Operational Programs & Advisory Services
Benefits and Worklife Division
Injury Compensation & Unemployment Compensation Branch
4800 Mark Center Drive, Suite 05G21
Alexandria, VA 22350-1100

Commercial Phone: (571) 372-1663
FAX: (571) 372-1662
DSN Phone: 372-1663
DSN FAX: 372-1662

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