Par.

1. Purpose

2. Responsibilities

3. Preparation of From FHWA-192

4. Health Benefits Enrollment - Survivor Annuitants

5. Burial and Associated Allowances

6. On-The-Job Injury Claims

7. Disposition of Completed Claims Forms

1. PURPOSE. This section sets forth procedures for processing death cases.

2. RESPONSIBILITIES.

   When an employee dies, sympathetic assistance will be furnished to survivors in settling matters relating to employment at the earliest appropriate time. The decedent's survivor(s) may have such entitlements as:

   (1) unpaid compensation

   (2) life insurance proceeds

   (3) a survivor annuity or lump sum payment of contributions to the Civil Service Retirement fund

   (4) continued health benefits coverage

   (5) burial and associated allowances and

   (6) transportation of remains, family and household goods at Government expense.

   The claim forms necessary to obtain such funds and benefits should be delivered to the next of kin within one week after the death of an employee.

   1. The supervisor is responsible for:

      (1) Reporting the death of an employee immediately to the servicing personnel office. The report shall include the deceased employee's name, whether death occurred as a result of an on-the-job injury, and, if known, date of death, next of kin, address of next of kin, and cause of death.

      (2) Furnishing assistance in coordination with the servicing personnel office, to the decedent's survivors in settling matters relating to employment.

   2. Personnel Office

      (1) Regional personnel offices shall immediately report the death of an employee to the Headquarters Office of Personnel and Training (HPT-21) and to the Office of Fiscal Services (HFS-20). The report shall include the deceased employee's name, whether death occurred as a result of an on-the-job injury, and if known, date of death, next of kin, address of next of kin and cause of death. Regional personnel offices shall prepare a letter of condolence from the Federal Highway Administrator.

      (2) The Headquarters Office of Personnel and Training (HPT-23) shall immediately report the death of an employee to the payroll office. HPT-23 shall request the Program Coordinator to prepare a letter of condolence from the Federal Highway Administrator.

      (3) The deceased employee's personnel office shall:

      (a) prepare the SF-52 (Request for Personnel Action);

      (b) prepare SF-2822, Agency Certification of Insurance Status and SF-2810, Notice of Change in Health Benefits Enrollment, (see paragraph 5) where applicable;

      (c) prepare Form FHWA-192, Claim Forms for Next of Kin or Designated Beneficiary, as described in paragraph 4. If the deceased's Official Personnel Folder is centralized, the Personnel Operations Division will provide, upon request by the regional personnel office, the name of any designated beneficiary and any information or forms necessary for preparation of Form FHWA-192 as described in paragraph (a);

      (d) forward the completed Form FHWA-192 to the official responsible for personal delivery, or if personal delivery is not possible, for mailing to the next of kin or designated beneficiary (see paragraph 3c);

      (e) serve as a source of technical information about completion of claim forms contained in Form FHWA-192, and

      (f) take appropriate action when completed claim forms are returned by the recipient of the kit as described in paragraph seven below.

   3. If the deceased is a field employee, the Regional Federal Highway Administrator shall designate an official to be responsible for delivery of the kit to the next of kin or designated beneficiary. If the deceased is a Washington Headquarters employee, the employee's Associate Administrator or Staff Office Director will designate an official to accompany a staff member from the Personnel Operations Division to deliver the kit.

   4. If death occurred while the employee was in travel status the ranking official of the local FHWA office shall immediately notify the appropriate personnel office and the ranking official at the employee's official duty station who in turn shall: (1) notify the employee's supervisor; (2) make arrangements for the notification of next of kin, and (3) provide every reasonable assistance in arranging for the preparation and transportation of the body (see paragraph 5).

3. PREPARATION OF FORM FHWA-192. Claim Form for Next of Kin or Designation of Beneficiary.

   1. Form FHWA-192. Claim Forms for Next of Kin or Designated Beneficiary, shall be used by personnel offices in transmitting to survivors the forms and other documents required in support of claims for amounts due the deceased employee's estate. The following instructions shall be observed in completing the form letter portion of the kit (Attachment 1):

      (1) The office, bureau, region or division identification shall be typed on the cover page under the "Federal Highway Administration."

      (2) Enter the deceased employee's name as carried on official personnel records.

      (3) Enter the name and address of the surviving spouse, the designated beneficiary, the next of kin, executor or administrator of the estate, as appropriate. If there is no designated beneficiary or surviving spouse, the following order of precedence prevails in the payment of benefits due a deceased employee:

      (a) To the deceased's child or children in equal share with the share of any deceased child distributed among the survivors of that child;

      (b) If none of the above, to the deceased's parents in equal shares or the entire amount to the surviving parent;

      (c) If none of the above, to the executor or administrator of the estate; or

      (d) If none of the above, to the next of kin as determined under the laws of the State in which the deceased was domiciled.

      (4) Items 1 and 2 - Employee Compensation Benefits. When an employee dies because of a personal injury incurred while in the performance of duty, check Form CA-5, and/or Form CA-5b.

      (5) Item 3 - Claim for Survivor Benefits under the Federal Employees Group Life Insurance Act of 1954. If the deceased was insured under FEGLI, check Form FE-6 provided the addressee is the appropriate person or representative to file the claim. If the decedent has named a beneficiary on SF-2823, Designation of Beneficiary, the benefits under FEGLI are payable only to the designated beneficiary.

      (6) Items 4, 5 and 6 - Claim for Unpaid Compensation. In addition to salary earned and unpaid at the date of death, "unpaid compensation" includes, but is not limited to, payments for annual leave, bond deductions, travel per diem, and other amounts for which the employee would have been paid. Check one block only under these items. If there is a surviving spouse or designated beneficiary (other than the estate) check SF-1153. If there is no surviving spouse or designated beneficiary (other than the estate) check SF-1155. If the designated beneficiary is the estate, check SF-1055.

      (7) Item 7 - Application for Death Benefits, Civil Service Retirement System. Check Form SF-2800 if the deceased was subject to the Civil Service Retirement Act.

      (8) Items 8 and 9 - Health Benefits Enrollment. Check Form SF-2810 if the deceased was enrolled in the Federal Employees Health Benefits Program. Check item 9 if the deceased was not enrolled.

      (9) Items 10 and 11 - Federal Credit Unions. If the decedent was employed in an area serviced by the Transportation Federal Credit Union, the servicing office of the Credit Union should be queried to determine whether the decedent had funds to his/her credit. The applicable item shall be checked. If funds to the credit of the deceased are to be paid to an administrator, executor, or legal representativeof the estate, an additional copy of the death certificate is required.

      (10) Items 12 and 13 - Military Service. Check the appropriate block on Form FHWA-192, if the deceased employee served in the military service or was in receipt of military retired pay.

      (11) Items 14-18. Check appropriate blocks on Form FHWA-192 to indicate items that must be returned, such as, uncashed Government checks, building passes, etc., and to attract attention to other useful information.

      (12) Enclose in the Kit three copies of all required applicable forms, a return envelope pre-addressed with the address of the preparing personnel office and include such other supplemental instructions necessary to provide guidance in completion and return of the forms.

      (13) Enter the name and address of the person issuing the kit and providing assistance to the family.

   2. Delivery of Completed Kit. When possible, the completed Form FHWA-192 shall be delivered to the next of kin or designated beneficiary personally by the designated official. If personal delivery of the kit is impossible, it shall be mailed, accompanied by an appropriate transmittal letter, within one week after notification of death is received.

4. HEALTH BENEFITS ENROLLMENT - SURVIVOR ANNUITANTS.

   1. Requirements for Continuing Enrollment. All of the following requirements must be met for a surviving family member of a deceased employee to continue health benefits enrollment:

      (1) the deceased employee must have been enrolled for self and family at the time of his/her death;

      (2) at least one family member must be entitled to a monthly annuity as the survivor of the deceased employee under the Civil Service Retirement System; and

      (3) if the monthly annuity of the survivor is insufficient to pay the premium required for enrollment in a plan, the survivor can make a direct payment to the Office of Personnel Management to cover the insurance premium.

   2. Procedure.

      (1) Employee Not Enrolled. If the deceased employee was not enrolled for health benefits, no action is required of the personnel office. All health benefits forms should be left in the decedent's official personnel folder.

      (2) Employee Enrolled, Survivor(s) Ineligible for Continued Enrollment. If the deceased employee was enrolled for health benefits but the survivor(s) is ineligible for continued enrollment because of failure to meet any one of the requirements listed under paragraph a above, terminate the enrollment on SF-2810. Note in the remarks: "Enrolled died (date)" and leave all health benefits forms in the official personnel folder. Send the enrolled copy of the SF-2810 to the nearest living relative or representative of the estate. However, if there is a survivor who has been covered as a member of the family and it appears that person may be eligible for conversion, send the SF-2810 to him/her. If survivor eligibility for continued coverage is questionable, the survivor should be given the benefit of the doubt and the enrollment shall be transferred to the Office of Personnel Management for decision.

      (3) Employee Enrolled, Survivor(s) Eligible for Continued Enrollment. If the survivor(s) appear eligible to continue enrollment, the personnel office shall:

      (a) prepare SF-2810, Notice of Change in Health Benefits Enrollment, transferring the enrollment to the Office of Personnel Management, Washington, D.C. 20415. Note in the remarks: "Employee died (date)",

      (b) include the original copy of the SF-2809 in the kit for next of kin with explanatory letter,

      (c) send to the servicing payroll office, the duplicate, triplicate, and quadruplicate copies of SF-2810, together with triplicate copies of all SF-2809's signed by the employee (including any in which he elected not to enroll) and any medical certificates attached thereto, and

      (4) Prompt Submission of Forms. Submission to the Office of Personnel Management of Standard Forms 2806, 2809, and 2810 shall not be delayed pending receipt of the SF-2800, Application for Death Benefits, although this document should be forwarded simultaneously if it is available or can be obtained quickly.

5. BURIAL AND ASSOCIATED ALLOWANCES.

   1. Preparation of Employee Remains:

      (1) FHWA is authorized to pay up to but not more than $250 for preparing the remains of an employee who dies while traveling on official business within the contiguous United States. When death occurs during travel status outside the contiguous United States or at the official station outside the United States, the Administrator or his designated representative is authorized to allow actual costs for preparation of the remains.

      (2) These costs include: (1) embalming or cremation; (2) necessary clothing; (3) casket or container suitable for shipment to place of interment; and (4) expenses necessarily incurred in complying with local laws and laws at the port of entry in the United States applicable to the preparation of remains for transportation and burial. When the FHWA must pay inexcess of that allowed by law, the beneficiary of the employee's estate will be billed by FHWA for the excess amount. If FHWA must pay costs in excess of that authorized by law and must consequently bill the beneficiary of the employee's estate, the personnel officer shall submit, through channels, to the Associate Administrator for Administration a request for approval including justification therefore.

      (3) When an employee dies as a result of an injury sustained in the performance of duty, under the terms of the Federal Employees' Compensation Act, the Office of Workers' Compensation Programs will arrange to pay the personal representative of the decedent for funeral and burial expenses not in excess of $800 and an additional sum of $200 for reimbursement of the costs of termination of the deceased's status as an employee of the United States. Payment may not be made by FHWA for preparing the remains of an employee where provisions of the Federal Employees' Compensation Act or any other law is applicable; however, the allowances herein described shall not be denied because the deceased employee is eligible for burial as a veteran of the Armed Forces of the United States.

   2. Transportation of Remains, Family and Household Goods.

      DOT Travel Manual, DOT Order 1500.6, Paragraph 336, outlines travel and transportation expenses FHWA is authorized to pay when an employee dies.

6. ON-THE-JOB INJURY CLAIMS.

   1. The supervisor shall report the death of an employee who dies because of a personal injury incurred while in the performance of duty immediately to the local personnel office in accordance with reporting requirements outlined in FWHA Personnel Management Manual, Chapter 10, Section 1.

   2. The personnel office shall provide guidance to the deceased's next of kin or appropriate estate representative in filing claims for benefits due.

   3. If application for return of the body is not made by the deceased's relatives, the Office of Workers' Compensation Programs should be notified and instruction requested for disposition of the remains.

7. DISPOSITION OF COMPLETED CLAIMS FORMS.

   When the completed claim forms, including the death certificate, are received, the personnel office shall take the following actions:

   1. Forward to the payroll office:

      (1) Payroll copy of SF-50.

      (2) Claim for Unpaid Compensation (Standard Form 1153).

      (3) Copy of the death certificate.

      (4) Any unnegotiated U.S. Treasury checks.

   2. Forward to the Headquarters Personnel Office:

      (1) SF-2800, Application for Death Benefits, Civil Service Retirement System, original. Attach one copy of the death certificate with health benefits enrollment status change, SF-2810.

      (2) FE-6, Claim for Death Benefits under Federal Employees Group Life Insurance, original. Attach the following:

      (a) an original death certificate, and

      (c) the original of the SF-54 and/or SF-2823, Designation of Beneficiary.

   3. Forward directly to the local office of the Office of Workers' Compensation Programs the original copy of each employee compensation claim (Forms CA-5, CA-5b), and/or other forms or documents in support of claims for burial expenses. A copy of each of the Office of Workers's Compensation Programs claim forms shall be filed in the Official Personnel Folder on the permanent side.

   4. Survivors of the deceased with accounts at Federal credit unions must present an original death certificate to claim payment of funds.