Ca 5 claim for compensation fby widow form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the name of the deceased employee in the first field, followed by their date of birth and social security number.
3. Fill in the dates of injury and death, ensuring accuracy as these are critical for processing your claim.
4. Provide details about the employing agency, including its name and address. This information is essential for verification purposes.
5. Complete sections regarding your relationship with the deceased, including your date of marriage and whether you were living together at the time of death.
6. List all children from this marriage and any prior marriages who may be entitled to compensation, along with their birth dates and addresses.
7. If applicable, include information about any legal guardianship or other relatives dependent on the deceased.
8. Finally, review all entries for accuracy before signing and dating the form. Attach any required documents such as marriage or birth certificates.

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