Get Form Ca 5 Claim For Compensaion By Widow, Widower, And Or Children

This guide provides step-by-step instructions on how to complete the Form CA 5 Claim For Compensation By Widow, Widower, And Or Children online. Designed for ease of use, it aims to assist you in accurately filling out the form to ensure a smooth submission process.

Follow the steps to successfully complete your form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the name of the deceased employee in the first section, providing their last, first, and middle names.
3. Input the date of birth of the deceased employee using the format (mo., day, year).
4. Provide the date of death in the same format as above.
5. Fill in the Social Security Number of the deceased to ensure proper identification.
6. In the section regarding the employing agency, list the name and complete address, including ZIP Code.
7. Indicate the date of injury that caused the death.
8. Answer questions about your relationship to the deceased, including your date of birth and marriage details.
9. List all children entitled to compensation, providing their names, relationships, dates of birth, and addresses.
10. Complete any sections about other relatives who may have been dependent on the deceased, along with their details.
11. Confirm any prior applications for federal benefits or claims against third parties related to the employee's death.
12. Review all information entered to ensure accuracy and completeness, marking any non-applicable items as 'NA'.
13. After completing the form, save changes, and download or print a copy for your records. Share the completed form online as needed.

Start your claim process now by filling out the Form CA 5 online.