Form CA-5, Claim for Compensation Instructions
This form contains 121 fields organized into 24 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Information | ||
| topmostSubform[0].Page1[0].radYN0_p2_17[1]_0 | ComboBox |
Select this option if applicable. (Specific context not provided in the form description)
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| topmostSubform[0].Page1[0].radYN0_p2_17[1]_1 | ComboBox |
Select this option if applicable. (Specific context not provided in the form description)
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| Bank Information | ||
| Enter routing or transit number | Text |
Enter the routing or transit number for the bank account.
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| Benefit Information | ||
| Enter amount (in dollars) of benefit paid per month | Text |
Enter the amount of benefit paid per month in dollars.
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| Enter date benefit began (MM/DD/YYYY) | Text |
Enter the date when the benefit began in the format MM/DD/YYYY.
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| Enter date benefit began (MM/DD/YYYY) | Text |
Enter the date when the benefit began in the format MM/DD/YYYY.
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| Burial Expenses | ||
| Enter name of party whose funds were used to pay burial expense | Text |
Enter the name of the person or entity whose funds were used to pay for the burial expenses of the deceased employee.
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| Enter address of party whose funds were used to pay burial expense | Text |
Enter the address of the person or entity whose funds were used to pay for the burial expenses of the deceased employee.
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| Child Information | ||
| Enter child's address | Text |
Enter the address of the child. This should include street address, city, state, and ZIP code.
|
| Enter name of employee's child from this marriage | Text |
Enter the full name of the employee's child from the current marriage.
|
| Enter relationship | Text |
Specify the relationship of the child to the deceased employee (e.g., son, daughter).
|
| Enter child's address | Text |
Enter the address of the child. This should include street address, city, state, and ZIP code.
|
| Enter name of employee's child from this marriage | Text |
Enter the full name of the employee's child from the current marriage.
|
| Enter relationship | Text |
Specify the relationship of the child to the deceased employee (e.g., son, daughter).
|
| Enter child's address | Text |
Enter the address of the child. This should include street address, city, state, and ZIP code.
|
| Enter name of employee's child from a prior marriage | Text |
Enter the full name of the employee's child from a prior marriage.
|
| Enter relationship | Text |
Specify the relationship of the child to the deceased employee (e.g., son, daughter).
|
| Enter child's address | Text |
Enter the address of the child. This should include street address, city, state, and ZIP code.
|
| Enter name of employee's child from a prior marriage | Text |
Enter the full name of the employee's child from a prior marriage.
|
| Enter relationship | Text |
Specify the relationship of the child to the deceased employee (e.g., son, daughter).
|
| Enter child's address | Text |
Enter the address of the child. This should include street address, city, state, and ZIP code.
|
| Enter name of employee's child from a prior marriage | Text |
Enter the full name of the employee's child from a prior marriage.
|
| Enter relationship | Text |
Specify the relationship of the child to the deceased employee (e.g., son, daughter).
|
| Enter child's address | Text |
Enter the address of the child. This should include street address, city, state, and ZIP code.
|
| Enter name of child who has been appointed a legal guardian | Text |
Enter the full name of the child who has been appointed a legal guardian.
|
| Enter name of child who has been appointed a legal guardian | Text |
Enter the full name of the child who has been appointed a legal guardian.
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| Enter child's date of birth (MM/DD/YYYY) | Text |
Enter the date of birth of the child in the format MM/DD/YYYY.
|
| Enter child's date of birth (MM/DD/YYYY) | Text |
Enter the date of birth of the child in the format MM/DD/YYYY.
|
| Enter child's date of birth (MM/DD/YYYY) | Text |
Enter the date of birth of the child in the format MM/DD/YYYY.
|
| Enter child's date of birth (MM/DD/YYYY) | Text |
Enter the date of birth of the child in the format MM/DD/YYYY.
|
| Enter child's date of birth (MM/DD/YYYY) | Text |
Enter the date of birth of the child in the format MM/DD/YYYY.
|
| Enter child's date of birth (MM/DD/YYYY) | Text |
Enter the date of birth of the child in the format MM/DD/YYYY.
|
| Children Information | ||
| Enter name of employee's child from this marriage | Text |
Enter the name of the child from the marriage with the deceased employee.
|
| Circumstances of Death | ||
| topmostSubform[0].Page2[0].radYN0_p1_10yn[0]_1 | ComboBox |
Select 'Yes' or 'No' to indicate if the deceased employee's death was work-related.
|
| Claim Information | ||
| topmostSubform[0].Page1[0].radYN0_p2_17[0]_3 | ComboBox |
Select 'Yes' or 'No' to indicate if the claim is being filed.
|
| Enter claim number | Text |
Enter the claim number associated with the deceased employee's case.
|
| Enter claim number | Text |
Enter the claim number associated with the deceased employee's case.
|
| Enter VA claim number | Text |
Enter the VA claim number if applicable.
|
| Enter address of VA office where claim is filed | Text |
Enter the address of the VA office where the claim is filed.
|
| Claimant Information | ||
| Enter relationship | Text |
Enter the relationship of the claimant to the deceased employee (e.g., spouse, child, guardian).
|
| Enter address | Text |
Enter the address of the claimant or the person filling out this form.
|
| Enter city | Text |
Enter the city of the claimant or the person filling out this form.
|
| Choose state | ComboBox |
Choose the state of the claimant or the person filling out this form from the provided list.
AR
WV
MO
OK
UT
VA
NJ
VI
GA
DC
DE
FM
ME
PW
MH
OH
RI
NV
ID
PA
SC
NC
IN
LA
MS
TX
CA
WA
MD
GU
WY
PR
AZ
OR
TN
NH
MI
CT
KS
KY
NY
CO
MN
AK
ND
NM
VT
WI
AL
MT
NE
MP
HI
IA
IL
AS
FL
MA
SD
|
| Enter your date of birth (MM/DD/YYYY) | Text |
Enter your date of birth in the format MM/DD/YYYY.
|
| Enter date of marriage to employee (MM/DD/YYYY) | Text |
Enter the date of your marriage to the deceased employee in the format MM/DD/YYYY.
|
| Enter name | Text |
Enter the full name of the claimant (surviving spouse or guardian).
|
| Enter street address | Text |
Enter the street address of the claimant.
|
| Enter city | Text |
Enter the city of the claimant's address. Maximum length is 30 characters.
|
| Choose state | ComboBox |
Choose the state from the provided list where the claimant resides.
AR
WV
MO
OK
UT
VA
NJ
VI
GA
DC
DE
FM
ME
PW
MH
OH
RI
NV
ID
PA
SC
NC
IN
LA
MS
TX
CA
WA
MD
GU
WY
PR
AZ
OR
TN
NH
MI
CT
KS
KY
NY
CO
MN
AK
ND
NM
VT
WI
AL
MT
NE
MP
HI
IA
IL
AS
FL
MA
SD
|
| Telephone number | Text |
Enter the telephone number of the claimant.
|
| Claims Information | ||
| topmostSubform[0].Page2[0].radYN0_p1_9yn[0]_0 | ComboBox |
Select 'Yes' or 'No' to indicate if there were any other claims made for benefits.
|
| topmostSubform[0].Page2[0].radYN0_p1_9yn[0]_1 | ComboBox |
Select 'Yes' or 'No' to indicate if there were any other claims made for benefits.
|
| Contact Information | ||
| Telephone number | Text |
Enter the telephone number of the claimant or the person filling out the form.
|
| Telephone number | Text |
Enter the telephone number of the claimant or the person filling out the form.
|
| Telephone number | Text |
Enter the telephone number of the claimant or the person filling out the form.
|
| Telephone number | Text |
Enter the telephone number of the claimant or the person filling out the form.
|
| Deceased Employee Information | ||
| Enter last name of deceased employee | Text |
Enter the last name of the deceased employee.
|
| Enter first name of deceased employee | Text |
Enter the first name of the deceased employee.
|
| Enter middle initial of deceased employee | Text |
Enter the middle initial of the deceased employee.
|
| Enter date of birth (MM/DD/YYYY) of deceased employee | Text |
Enter the date of birth of the deceased employee in MM/DD/YYYY format.
|
| Enter date of injury (MM/DD/YYYY) of deceased employee | Text |
Enter the date of injury of the deceased employee in MM/DD/YYYY format.
|
| Enter date of death (MM/DD/YYYY) of deceased employee | Text |
Enter the date of death of the deceased employee in MM/DD/YYYY format.
|
| Enter service number | Text |
Enter the service number of the deceased employee.
|
| Enter social security number (XXX-XX-XXXX) of deceased employee | Text |
Enter the social security number of the deceased employee in the format XXX-XX-XXXX.
|
| Enter last name of deceased employee | Text |
Enter the last name of the deceased employee.
|
| Enter first name of deceased employee | Text |
Enter the first name of the deceased employee.
|
| Enter middle initial of deceased employee | Text |
Enter the middle initial of the deceased employee. This field accepts only one character.
|
| Enter date of death (MM/DD/YYYY) of deceased employee | Text |
Enter the date of death of the deceased employee in MM/DD/YYYY format.
|
| Dependent Relative Information | ||
| Enter name of relative who is fully or partially dependent on employee | Text |
Enter the full name of the relative who is fully or partially dependent on the deceased employee.
|
| Enter relationship | Text |
Enter the relationship of the relative to the deceased employee (e.g., spouse, child, parent).
|
| Enter relative's address | Text |
Enter the complete address of the relative, including street, city, state, and ZIP code.
|
| Enter name of relative who is fully or partially dependent on employee | Text |
Enter the full name of the relative who is fully or partially dependent on the deceased employee.
|
| Enter relationship | Text |
Enter the relationship of the relative to the deceased employee (e.g., spouse, child, parent).
|
| Enter relative's address | Text |
Enter the complete address of the relative, including street, city, state, and ZIP code.
|
| Employing Agency Information | ||
| Enter name of employing agency | Text |
Enter the name of the employing agency where the deceased employee worked.
|
| Enter street address of employing agency | Text |
Enter the street address of the employing agency.
|
| Enter city of employing agency | Text |
Enter the city where the employing agency is located.
|
| Choose state of employing agency | ComboBox |
Choose the state where the employing agency is located from the provided list.
AR
WV
MO
OK
UT
VA
NJ
VI
GA
DC
DE
FM
ME
PW
MH
OH
RI
NV
ID
PA
SC
NC
IN
LA
MS
TX
CA
WA
MD
GU
WY
PR
AZ
OR
TN
NH
MI
CT
KS
KY
NY
CO
MN
AK
ND
NM
VT
WI
AL
MT
NE
MP
HI
IA
IL
AS
FL
MA
SD
|
| Financial Information | ||
| Enter amount of recovery | Text |
Enter the amount of recovery received or expected.
|
| Enter total burial amount | Text |
Enter the total amount of burial expenses.
|
| Enter amount of burial expense paid or payable by VA | Text |
Enter the amount of burial expenses paid or payable by the VA.
|
| Enter account number | Text |
Enter the account number where the benefits should be deposited.
|
| Enter name of financial institution | Text |
Enter the name of the financial institution where the benefits should be deposited. Maximum length is 20 characters.
|
| Enter amount (in dollars) of benefit paid per month | Text |
Enter the amount of benefit paid per month in dollars.
|
| Enter amount of burial expense | Text |
Enter the amount of burial expense incurred.
|
| Form Actions | ||
| Print form | Button |
Click this button to print the form.
|
| Reset form | Button |
Click this button to reset the form to its default state.
|
| General Information | ||
| topmostSubform[0].Page1[0].radYN0_p2_11[0]_0 | ComboBox |
Select 'Yes' or 'No' to indicate if the specified condition or statement applies.
|
| topmostSubform[0].Page1[0].radYN0_p2_11[0]_1 | ComboBox |
Select 'Yes' or 'No' to indicate if the specified condition or statement applies.
|
| topmostSubform[0].Page1[0].radYN0_p2_12[0]_0 | ComboBox |
Select 'Yes' or 'No' to indicate if the specified condition or statement applies.
|
| topmostSubform[0].Page1[0].radYN0_p2_12[0]_1 | ComboBox |
Select 'Yes' or 'No' to indicate if the specified condition or statement applies.
|
| topmostSubform[0].Page1[0].radYN0_p2_13[0]_0 | ComboBox |
Select 'Yes' or 'No' to indicate if the specified condition or statement applies.
|
| topmostSubform[0].Page1[0].radYN0_p2_13[0]_1 | ComboBox |
Select 'Yes' or 'No' to indicate if the specified condition or statement applies.
|
| topmostSubform[0].Page1[0].radYN0_p2_17[0]_0 | ComboBox |
Select this option if the answer to the corresponding question is 'Yes'.
|
| topmostSubform[0].Page1[0].radYN0_p2_17[0]_1 | ComboBox |
Select this option if the answer to the corresponding question is 'No'.
|
| topmostSubform[0].Page1[0].radYN0_p2_17[0]_2 | ComboBox |
Select this option if the answer to the corresponding question is 'Not Applicable'.
|
| Guardian Information | ||
| Enter guardian's name | Text |
Enter the full name of the guardian who is responsible for the child.
|
| Enter guardian's address | Text |
Enter the complete address of the guardian, including street, city, state, and ZIP code.
|
| Enter guardian's name | Text |
Enter the full name of the guardian who is responsible for the child.
|
| Enter guardian's address | Text |
Enter the complete address of the guardian, including street, city, state, and ZIP code.
|
| Incident Details | ||
| Enter nature of injury which caused death | Text |
Enter the nature of the injury that caused the death of the employee.
|
| Enter history of injury | Text |
Provide a detailed history of the injury that led to the death of the employee.
|
| Medical Information | ||
| Enter diagnosis | Text |
Enter the medical diagnosis related to the injury or disease that caused the death.
|
| Describe treatment | Text |
Describe the treatment that the deceased employee received for the injury or disease.
|
| Enter direct cause of death | Text |
Enter the direct cause of death as stated in the medical records.
|
| Enter contributory causes of death | Text |
Enter any contributory causes of death that may have been factors in the employee's death.
|
| Enter medical reasons | Text |
Provide the medical reasons that support the claim for compensation.
|
| topmostSubform[0].Page2[0].radYN0_p1_10yn[0]_0 | ComboBox |
Select 'Yes' or 'No' to indicate if there were any other medical reasons related to the claim.
|
| Medical Treatment Information | ||
| Enter date (MM/DD/YYYY) when treatment was given | Text |
Enter the date when treatment was given in MM/DD/YYYY format.
|
| Enter date (MM/DD/YYYY) when treatment was given | Text |
Enter the date when treatment was given in MM/DD/YYYY format.
|
| Enter date (MM/DD/YYYY) when treatment was given | Text |
Enter the date when treatment was given in MM/DD/YYYY format.
|
| Relative Information | ||
| Enter relative's date of birth (MM/DD/YYYY) | Text |
Enter the date of birth of the relative in the format MM/DD/YYYY.
|
| Enter relative's date of birth (MM/DD/YYYY) | Text |
Enter the date of birth of the relative in the format MM/DD/YYYY.
|
| Surviving Spouse Information | ||
| Enter name of surviving husband or wife | Text |
Enter the name of the surviving husband or wife.
|
| Enter street address of surviving husband or wife | Text |
Enter the street address of the surviving husband or wife.
|
| Enter city of surviving husband or wife | Text |
Enter the city where the surviving husband or wife currently resides.
|
| Choose state of of surviving husband or wife | ComboBox |
Select the state where the surviving husband or wife currently resides from the provided list.
AR
WV
MO
OK
UT
VA
NJ
VI
GA
DC
DE
FM
ME
PW
MH
OH
RI
NV
ID
PA
SC
NC
IN
LA
MS
TX
CA
WA
MD
GU
WY
PR
AZ
OR
TN
NH
MI
CT
KS
KY
NY
CO
MN
AK
ND
NM
VT
WI
AL
MT
NE
MP
HI
IA
IL
AS
FL
MA
SD
|
| Third Party Information | ||
| Enter name of third party | Text |
Enter the name of the third party involved, if any.
|
| Enter address of third party | Text |
Enter the address of the third party involved, if any.
|
| Enter city of third party | Text |
Enter the city of the third party involved, if any.
|
| Choose state of third party | ComboBox |
Choose the state of the third party involved, if any.
AR
WV
MO
OK
UT
VA
NJ
VI
GA
DC
DE
FM
ME
PW
MH
OH
RI
NV
ID
PA
SC
NC
IN
LA
MS
TX
CA
WA
MD
GU
WY
PR
AZ
OR
TN
NH
MI
CT
KS
KY
NY
CO
MN
AK
ND
NM
VT
WI
AL
MT
NE
MP
HI
IA
IL
AS
FL
MA
SD
|