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Form CA-5, Claim for Compensation, page 1
Complex · 68/100Form Complexity Index

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What this form asks for

The AI fills all of it, from your answers or your documents.

Form CA-5, Claim for Compensation, is a form used by the surviving spouse and/or children of a deceased federal employee to apply for compensation benefits. This form is essential for ensuring that eligible dependents receive the financial support they are entitled to under the Federal Employees' Compensation Act (FECA).
Fillable fields121
Pages2
Sections24
Form Complexity IndexComplex, 68/100

The AI checks your answers before you download

15 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Filing Deadline Compliance

Ensures that the Claim for Compensation by Surviving Spouse and/or Children is filed within the stipulated three-year period following the date of death. It pays special attention to any exceptions that may be outlined in the instructions section of the form, taking into account different circumstances that could affect the filing deadline. The software alerts the user if the claim is being filed late and advises on the necessary steps to take if exceptions apply.

Complete Section Accuracy

Confirms that all required sections, numbered 1 through 28, are accurately completed with the correct details pertaining to the deceased employee, surviving spouse, children, and other dependents. It checks for consistency in the information provided across different sections and ensures that no mandatory fields are left blank. The software prompts the user to fill in any missing details before allowing the form to be submitted.

Surviving Spouse's Details Verification

Verifies that the surviving spouse's details, including but not limited to date of birth, date of marriage, and current address, are correctly entered in items 8 to 13 of the form. It cross-references these details with official documents to ensure accuracy. The software also checks for logical inconsistencies, such as dates that do not align with the provided narrative or historical records.

Supporting Documents Check

Checks for the inclusion of all necessary supporting documents such as marriage certificates, death certificates, and birth certificates. It ensures that these documents are properly attached to the claim form and are legible. The software also verifies that the information on the supporting documents matches the details entered on the claim form, flagging any discrepancies for user review.

Deceased Employee's Information Validation

Validates the accuracy of the deceased employee's personal information, including their name, date of birth, date of death, social security number, date of injury, and the nature of the injury that caused death. The software cross-verifies these details with external databases and records, if available, to ensure the claim is based on factual and consistent information.

Confirms the correct entry of bank details for Direct Deposit

The AI ensures that the bank details provided for Direct Deposit are accurate and complete. It checks that the name of the financial institution, type of account, account number, and routing or transit number are correctly entered in items 23-25. The AI cross-references these details with known banking formats to prevent errors. It also alerts the user if any field is left blank or contains invalid characters that do not conform to standard banking information.

And 9 more checks
  • Verifies that all children from the marriage with the employee and from prior marriages are listed
  • Checks for the completion of the Attending Physician's Report section
  • Ensures that the claim form is signed and dated
  • Confirms information on any other Federal Retirement or Disability Law claims
  • Verifies the completeness and accuracy of the details of any legal guardians for the children listed in the form.
  • Checks for the inclusion of details of other relatives who were fully or partially dependent on the employee.
  • Ensures that the Privacy Act Notice and Public Burden Statement have been read and understood.
  • Confirms that the form is not sent to the OMB office but is submitted to the Office of Workers' Compensation Programs.
  • Verifies that the instructions for completing Form CA-5 have been reviewed and followed, including additional details on required documents, funeral/burial allowance, definition of dependents, compensation rates, third-party action, and direct deposit information.

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How to Fill Out Form CA-5 Online for Free in 2026

What the AI walks you through.

  1. Visit instafill.ai site and select Form CA-5.
  2. Enter the deceased employee's details.
  3. Provide information about the claimants.
  4. Fill in the financial institution details.
  5. Sign and date the form electronically.
  6. Check for accuracy and submit the form.

Common Mistakes in Completing Form CA-5

The ones the AI is built to catch.

Incomplete or inaccurate information about the deceased employee
One of the most common mistakes made when filling out the Claim for Compensation by Surviving Spouse and/or Children form is failing to provide accurate and complete information about the deceased employee. This can include incorrect Social Security number, incorrect or incomplete employment history, or missing dates of employment. To avoid this mistake, it is important to double-check all information provided about the deceased employee before submitting the form. It may also be helpful to gather all relevant employment records and documents before beginning the filing process.
Incomplete or inaccurate information about the surviving spouse and children
Another common mistake is failing to provide accurate and complete information about the surviving spouse and children. This can include incorrect or missing dates of birth, marriage, or relationship status. It is important to ensure that all required information is provided to avoid delays or denials of the claim. To avoid this mistake, it is recommended to gather all necessary documents, such as birth certificates and marriage certificates, before filling out the form.
Failure to list all children entitled to compensation
A mistake that can result in significant financial consequences is failing to list all children from the marriage and from prior marriages who may be entitled to compensation. It is important to carefully review the instructions on the form and ensure that all eligible children are included. Failure to list all children may result in the denial of their compensation or the need for a separate claim to be filed. To avoid this mistake, it is recommended to carefully review the instructions on the form and gather all necessary documentation, such as birth certificates, before filling out the form.
Incorrect bank account information for direct deposit
Another common mistake is providing incorrect bank account information for direct deposit. This can result in delayed or lost compensation. To avoid this mistake, it is important to double-check all bank account information before submitting the form. It may also be helpful to write down the account and routing numbers and keep a copy for your records.
Failure to sign and date the form or provide the address of the person filing the claim
Lastly, failure to sign and date the form or provide the address of the person filing the claim is a common mistake that can result in delays or denials of the claim. It is important to carefully review the instructions on the form and ensure that all required signatures and addresses are provided. To avoid this mistake, it is recommended to carefully review the instructions on the form and gather all necessary documentation, such as identification, before filling out the form.
Failure to attach all required documents
One of the most common mistakes when completing the Claim for Compensation by Surviving Spouse and/or Children form is the failure to attach all required documents. It is essential to include marriage certificates, death certificates, and birth certificates to support the claim. These documents provide proof of the relationship between the deceased and the surviving spouse or children, as well as their eligibility for benefits. To avoid this mistake, carefully review the instructions on the form and ensure that all required documents are gathered and attached before submitting the claim. It is also recommended to make copies of all documents for your records.
Failure to complete the Attending Physician's Report section properly
Another common mistake is incomplete or incorrect information provided in the Attending Physician's Report section. This section requires detailed information about the deceased's cause of death and any related medical conditions. Incomplete or incorrect information can lead to delays or denials of the claim. To avoid this mistake, ensure that the attending physician completes the section accurately and thoroughly, providing all necessary details about the deceased's medical history and cause of death. It is also recommended to double-check the information provided and follow up with the physician if any clarification is needed.
Failure to understand and follow instructions for completing the form
Failure to understand and follow the instructions for completing the form is a common mistake that can lead to errors and delays in processing the claim. The instructions provide important information about the deadline for filing, required documents, and completion of various sections. To avoid this mistake, carefully review the instructions before completing the form, and ask for clarification if anything is unclear. It is also recommended to take your time and ensure that all information is provided accurately and completely.
Failure to provide correct claim numbers, amounts of benefits, and details of third parties for previous Federal Retirement or Disability Law claims or Veterans Administration benefits
Providing incorrect claim numbers, amounts of benefits, and details of third parties for previous Federal Retirement or Disability Law claims or Veterans Administration benefits is a common mistake that can lead to delays or denials of the claim. It is essential to provide accurate and complete information about any previous claims or benefits to ensure that the current claim is processed correctly. To avoid this mistake, carefully review any previous claims or benefit statements and provide the correct information on the Claim for Compensation by Surviving Spouse and/or Children form. It is also recommended to double-check the information provided and follow up with the relevant agencies if any clarification is needed.
Failure to understand the Privacy Act Notice and Public Burden Statement and the implications for the use of personal information
Failure to understand the Privacy Act Notice and Public Burden Statement and the implications for the use of personal information is a common mistake that can lead to errors or concerns regarding the privacy of personal information. The Privacy Act Notice and Public Burden Statement provide important information about how personal information will be used and protected. To avoid this mistake, carefully review the notices and understand the implications for the use of personal information. It is also recommended to contact the relevant agency if any questions or concerns arise regarding the use of personal information.

Frequently Asked Questions About Form CA-5

 

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This plan is for your Form CA-5: your own AI agent fills it as often as 5 times a month. To fill other forms and upload your own, choose a Professional plan from your account.
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How does the AI fill out Form CA-5?
You answer a few questions in plain words, or upload a document you already have. The AI reads what you give it and puts each answer into the right field of Form CA-5, on every page, in seconds. It checks the answers against the form's own rules, and you review and change anything before you download, print or sign.
What happens to my information?
It is encrypted in transit and at rest, and it is never used to train AI.
How complex is Form CA-5 to fill out?
Form CA-5 has a Form Complexity Index of 68 out of 100, in the complex tier: 121 fillable fields across 2 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is the purpose of the 'Claim for Compensation by Surviving Spouse and/or Children' form?
This form is used by the surviving spouse or children of a deceased employee to apply for compensation benefits under the Federal Employees' Compensation Act (FECA).
Who should complete and file this form?
The surviving spouse or children of the deceased employee should complete and file this form. If there is no surviving spouse, the children's guardian should file the claim.
What is the deadline for filing this claim?
The claim must be filed within three years following the date of death, unless the employer had actual knowledge of an on-the-job injury or death within 30 days or written notice of the injury or death was given within 30 days.
What documents are required to be submitted with the claim form?
The required documents include the marriage certificate(s) for a surviving spouse, death certificate for the decedent, birth certificate or adoption documents for each child, and any appropriate letters of guardianship.
What types of benefits are available under the FECA for surviving spouses and children?
Surviving spouses may be eligible for 50% of the employee's monthly pay if there are no surviving eligible children, or 45% if there are eligible children. Children are eligible for 15% each, not to exceed a total of 30%, shared equally if there is a surviving spouse; if there is no surviving spouse, 40% for one child plus 15% for each additional child, shared equally.
What happens if the surviving spouse remarries before age 55?
Upon remarriage before age 55, the surviving spouse will receive a lump sum equal to 24 times his or her monthly compensation. If the remarriage occurs at age 55 or later, payments continue for life.
What funeral and burial expenses are covered under the FECA?
The FECA covers funeral and burial expenses up to a maximum of $800. Any amount paid by the VA will be deducted, and transportation costs may also be paid to return the deceased employee to his or her home or last place of residence.
What should be done if the injury or death results from the actions of a third party?
In cases where the injury or death results from the actions of a third party, the Department of Labor will provide further instructions.
What is the Privacy Act Notice and why is it important?
The Privacy Act of 1974 requires the Office of Workers' Compensation Programs to maintain personal information on claimants and their immediate families for the purpose of determining eligibility for and the amount of benefits payable under the FECA. This information may be verified through computer matches or other appropriate means and may be given to various federal, state, and local agencies for law enforcement purposes and other relevant matters.
What is the public reporting burden for this collection of information?
The public reporting burden for this collection of information is estimated to average 90 minutes per response.
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