Claim For Continuance of Compensation Under the Federal Employees' Compensation Act

• Legal Form Number: CA-12
• Issuer: Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation
• Section: U.S. Department of Labor

INSTRUCTION TO BENEFICIARIES

1. It is important that you carefully complete the other side of this form and return it to the OWCP within 30 days. Your failure to do so will result in

suspension of the compensation you are receiving.

2. Complete Section A by printing the full name of the deceased employee and the OFFICE OF WORKERS' COMPENSATION PROGRAMS file

number.

3. Answer all questions in the section or sections that apply to you. If you are receiving compensation as the:

(A) SURVIVING SPOUSE - Complete Section B.

(B) SURVIVING SPOUSE RECEIVING COMPENSATION ON HER OR HIS ACCOUNT AND ON ACCOUNT OF A MINOR CHILD OR CHILDREN -

Complete Sections B and C.

(C) GUARDIAN OR CUSTODIAN OF A MINOR CHILD OR GRANDCHILD OR A PERSON INCAPABLE OF SELF-SUPPORT - Complete Section C.

(D) PARENT, GRANDPARENT, OR A PERSON WHO IS PHYSICALLY INCAPABLE OF SELF-SUPPORT - Complete Section D.

4. Carefully read and comply with directions in Section E.

5. Complete and sign the certificate in Section F.

6. Please return the completed form, in an envelope, to the address shown below.

Claim for Continuance of Compensation

Under the Federal Employees'

Compensation Act

U.S. Department of Labor

Office of Workers' Compensation Programs

OMB No. 1240-0015

Expires: 01/31/2027

The information on this form will be used to determine your eligibility for continuing benefits. Your response to this information is required to

retain your compensation benefits. Your benefits may be suspended if you fail to return this form within 30 days of the date of the request. (20 CFR

10.414)

RETURN TO: OWCP/DFELHWC-FECA

PO Box 8311

London, KY 40742-8311

(202) 513-6860

OR

You can electronically upload documents into your case using the Employees’ Compensation Operations and Management Portal (ECOMP).

You can access ECOMP from any internet browser at: https://www.ecomp.dol.gov/ . When you access the website, choose the "Upload

Document" option. You will be asked to provide your case number, last name, date of birth and date of injury to upload a document. ECOMP

will then provide you with a Tracking Number so that you can verify when OWCP has received your document. For more detailed

information about this document submission feature, visit the ECOMP website and click "Help."

Privacy Act

The Privacy Act of 1974 as amended, (5 U.S.C. 552a), and the Federal Employees’ Compensation Act, as amended and extended (5 U.S.C 8101, et.

seq) authorizes collection of this information. The information will be used to determine continuing entitlement to benefits. Furnishing the requested

information is required for a claimant to obtain or retain a benefit. Failure to provide the information may result in the delay of a claim or payment of

benefits, or may result in an unfavorable decision or reduced levels of benefits. Additional disclosures of this information made: (1) to determine

eligibility for and the amount of benefits payable under the FECA, and may be verified through computer matches or other appropriate means; (2) to the

Federal agency which employed the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the

claim, verify billing, and to consider issues relating to retention, rehire, or other relevant matters; (3) to other Federal agencies, other government

entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services; (4) to physicians and

other healthcare providers for use in providing treatment or medical/vocational rehabilitation, making evaluations for the Office, and for other purposes

related to the medical management of the claim; and (5) to Federal, state and local agencies for law enforcement purposes, to obtain information

relevant to a decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are being

made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt

Collection Act.

Public Burden Statement

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Public reporting burden for

this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions, searching existing data sources,

gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this

estimate or any other aspect of this information collection, including suggestions for reducing this burden, please send them to the Department of Labor,

Office of Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, N.W. Washington, D.C. 20210. DO NOT SEND THE

COMPLETED FORM TO THIS OFFICE..

CA-12

(Rev. 10-17)

Accommodation Statement

If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/

or modifications, please contact OWCP.