CA-5 Claim for Compensation by Surviving Spouse and/or Children

• Form CA-5 should be completed and filed by the surviving spouse for self and any surviving children. If there is no surviving spouse, the child(ren)'s guardian completes the form.
• Claim should be filed within 30 days, if possible, but no later than  three years after the date of death, unless the decedent's immediate superior 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.
• The timely filing of a disability claim will satisfy the time requirements for a death claim based on the same injury. Must still give written notice within 30 days of the date of death.