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U.S. Department of Labor (Federal Workers Compensation Consultants)

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U.S. Department of Labor
Office of Workers' Compensation Programs
Claim for Compensation
SECTION 1 EMPLOYEE PORTION
Middle
OMB No. 1240-0046
Expires: 03-31-2021
First
a. Name of Employee Last
c. OWCP File Number
b. Mailing Address ( Including City State, ZIP Code )
d. Date of Injury e. Social Security Number
Month Day Year
E-Mail Address (Optional)
f. Telephone No./FAX No.
Compensation is claimed for:
Inclusive Date Range
Go to Section 3
Go to Section 3, and Complete Form CA-7b
Go to Section 3
Leave without pay
Leave buy back
Other wage loss; specify type,
such as downgrade, loss of
night differential, etc.
Type:
SECTION 2
From Intermittent?
To
If intermittent, complete Form CA-7a,
Time Analysis Sheet
Schedule Award (Go to Section 4)
a.
b.
c.
d.
Yes No
Yes No
Yes No
SECTION 3 You must report any and all earnings from employment (outside your federal job); include any employment for which you received a salary,
wages, income, sales commissions, or payment of any kind during the period(s) claimed in Section 2. Include self-employment, odd jobs, involvement in
business enterprises, as well as service with the military. Fraudulently concealing employment or failing to report income may result in forfeiture of
compensation benefits and/or criminal prosecution. Have you worked outside your federal job for the period(s) claimed in Section 2? Refer to the
Instructions which provide further clarification.
Name and Address of Business:
ZIP CodeStateCityAddressName
Go to
section 4
Type of Work:Dates Worked:
Yes
No
Is this the first CA-7 claim for compensation you have filed for this injury?
Complete Sections 5 through 7 and a Form SF-1199A, "Direct Deposit Sign-up"
SECTION 4
Yes
No
Yes - Complete Sections 5 through 7 or a new SF-1199A to reflect change(s) No - Complete Section 7
If changes to dependent status, direct deposit information, or if a claim has been filed with the U.S. Civil Service Retirement, another federal
retirement/disability law, or with Department of Veteran Affairs, complete Sections 5 through 7 or a new SF-1199A. If no, complete Section 7.
SECTION 5 List your dependents (including spouse). If additional space is necessary, provide same information requested below on separate page(s)
and include your name/claim number at the top of the page(s).
Living with you?
Date of Birth
Yes No
Relationship
For dependents not living
with you complete items
a and b below. ,
a. Are you making support payments for a dependent noted above or on your attachment(s)?
ZIP CodeName
StateAddress City
b. Were support payments ordered by a court? If Yes, attach copy of court order.
If Yes, support payments are made to:
Name Social Security #
Yes No
Yes No
b. Have you ever applied for or received disability benefits from the Department of Veterans Affairs?
Claim Number
Full Address of VA Office Where Claim Filed
Nature of Disability and Monthly Payment
c. Have you applied for or received payment under any Federal Retirement or Disability law?
Claim Number
Date Annuity Began
Amount of Monthly Payment Retirement System (CSRS, FERS, SSA, Other)
a. Was/Will there be a claim made against a 3rd party?
SECTION 6
Yes No
Yes
No
Yes
No
CSRS FERS SSA Other
Employee's Signature
Date ( Mo., day, year)
SECTION 7 I hereby make claim for compensation because of the injury sustained by me while in the performance of my duty for the United States. I certify
that the information provided above is true and accurate to the best of my knowledge and belief. Any person who knowingly makes any false statement,
misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as provided by the FECA, or who knowingly accepts compensation to
which that person is not entitled is subject to civil or administrative remedies as well as criminal prosecution and may, under appropriate criminal provisions, be
punished by a fine or imprisonment, or both. In addition, a state or federal criminal conviction for FECA fraud will result in termination of all current and future
FECA benefits. I understand that by signing this form, if evidence is received suggesting possible employment or earnings, I authorize OWCP to request
verification of employment/earnings from the Social Security Administration.
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. See form instructions for Requests for Accommodations or Auxiliary Aids and Services.
Print
Reset
Employing Agency Portion
For first CA-7 claim sent, complete sections 8 through 15.
For subsequent claims, complete sections 12 through 15 only.
Show Pay Rate as of
SECTION 8
Additional Pay
Additional Pay Additional Pay
Base PayDate of Injury:
Date Employee Stopped Work:
Additional pay types include, but are not limited to: Night Differential (ND), Sunday Premium (SP), Holiday Premium (HP), Subsistence
(SUB), Quarter (QTR), etc. (List each separately)
Type
$
per
Grade: step:
Date:
$ per
Type
$ per
Type
$ per
Type
$ per
Type
$ per
Type
$ per
$
per
Grade:
Date:
step:
a. Does employee work a fixed 40-hour per week schedule?
SECTION 9
1. If Yes, circle scheduled days:
FOR EXAMPLE ONLY
S
M T W TH F
S
WEEK 1
5/20
5/14 to
WEEK
5/21
5/27
From
to
b. Did employee work in position for 11 months prior to injury?
If No, would position have afforded employment for 11 months but for the injury?
2. If No, show scheduled hours for the two week pay period in which work stopped. Circle the day that work stopped.
6
From
S
M
T
W TH
F
S
8
4
6
8 6 6
4
Yes No
S M T W T F S
From To
From To
Yes No
Yes No
c. Optional Life Insurance?
(D-Z only)
d. A Retirement System?
b. Basic Life Insurance?
(Specify CSRS, FERS, Other)
SECTION 10 On date pay stopped, was employee enrolled in:
a. Health Benefits under
the FEHBP?
Code
Plan
YesNo
YesNo
Class
YesNo
YesNo
Yes - Complete Time
Analysis Sheet, Form CA-7a
Intermittent?
No
SECTION 11 Continuation of Pay (COP) Received ( Show inclusive dates ):
From To
Intermittent?
If intermittent, complete Form
CA-7a, Time Analysis Sheet.
To
Sick Leave From
To
Annual Leave From
To
Leave without Pay From
If leave buy back, also submit
completed Form CA-7b.
To
Work From
SECTION 12 Show pay status and inclusive dates for period(s) claimed:
Yes No
Yes No
Yes No
Yes No
SECTION 13
If Yes, date
If returned, did employee return to the pre-date-of-injury job, with the same number of hours and the same duties?
If No, explain:
Yes No
Yes No
Did employee return to work?
SECTION 14
Remarks:
Signature Title Date
(Agency Official)
Name of Agency
If OWCP needs specific pay information, the person who should be contacted is:
Name Title
Telephone No. Fax No. E-Mail Address
SECTION 15 An employing agency official who knowingly certifies to any false statement, misrepresentation, or concealment of fact with respect to
this claim (or impedes the filing of a claim) may also be subject to appropriate criminal prosecution.
I certify that the information given above and that furnished by the employee on this form is true to the best of my knowledge, with any exceptions noted
in Section 14, Remarks, above.
/ /
Date Claim Form Received from Employee / /
INSTRUCTIONS FOR COMPLETING FORM CA-7
If additional space is needed to respond to questions on this form, attach a separate sheet of paper and write, “see attachment” in the applicable portion of
the form. Please ensure the claimant's full name and claim number appear on the separate sheet(s).
If the employee does not quality for continuation of pay (for 45 days), the form should be completed and filed with the OWCP as soon as pay stops. The
form should also be submitted when the employee reaches maximum improvement and claims a schedule award. If the employee is receiving
continuation of pay and will continue to be disabled after 45 days, the form should be filed with OWCP 5 working days prior to the end of the 45-day
period.
The CA-7 also should be used to claim continuing compensation, when a previous CA-7 claim has been made.
Collection of this information is required to obtain a benefit and is authorized by 20 C.F.R.10.102, 20 C.F.R.10.103, and 20 C.F.R.10.404.
Notice
Requests for Accommodations or Auxiliary Aids and Services
If you have a disability, federal law gives you the right to receive help from the OWCP in the form of communication assistance, accommodation(s) and/or
modification(s) to aid you in the claims process. For example, we will provide you with copies of documents in alternate formats, communication services
such as sign language interpretation, or other kinds of adjustments or changes to accommodate your disability. Please contact our office or your OWCP
claims examiner to ask about this assistance.
EMPLOYEE (or person acting on the employee's behalf) - Complete sections 1 through 7 as directed and submit the form to the employee's supervisor.
SUPERVISOR
(or appropriate official in the employing agency) - Complete sections 8 through 15 as directed and promptly forward the form to the
OWCP.
EXPLANATIONS
- Some of the items on the form which may require further clarification are explained below:
Section Number
Explanation
2d. Schedule Award
Schedule awards are paid for permanent impairment to a member or function of the body.
5. List your dependents
Your spouse is a dependent if he or she is living with you. A child is a dependent if he, or she either lives with
you or receives support payments from you, and he or she: 1) is under 18, or 2) is between 18 and 23 and is
a full-time student, or 3) is incapable of self-support due to physical or mental disability.
6a. Was/will there be a claim
made against 3rd party?
A third party is an individual or organization (other than the injured employee or the Federal government)
who is liable for the injury. For instance, the driver of a vehicle causing an accident in which an employee is
injured, the owner of a building where unsafe conditions cause an employee to fall, and a manufacturer who
gave improper instructions for the use of a chemical to which an employee is exposed, could all be
considered third parties to the injury.
''Additional Pay'' includes night differential, Sunday premium, holiday premium, and any other type (such as
hazardous duty or ''dirty work'' pay) regularly received by the employee, but does not include pay for
overtime. If the amount of such pay varies from pay period to pay period (as in the case of holiday premium
or a rotating shift), then the total amount of such pay earned during the year immediately prior to the date of
injury or the date the employee stopped work (whichever is greater) should be reported.
8. Additional Pay
11. Continuation of pay (COP)
received
If the injury was not a traumatic injury reported on Form CA-1, this item does not apply.
14. Remarks This space is used to provide relevant information which is not present elsewhere on the form.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
3. Employment An employee who either claims or is receiving compensation for partial or total disability must advise OWCP
immediately of any return to work. An employee must report all outside employment, including any
concurrent dissimilar employment held at the time of injury. The employee must report even those earnings
which do not seem likely to affect benefits; failure to report earnings may result in forfeiture of all benefits
paid during the period for which compensation is claimed. For example, include sales, farming, and operating
(or keeping books for) a business including a family business. Report providing services (such as carpentry,
mechanical work, child care, odd jobs) provided in exchange for money, goods, or other services. Report
part-time or intermittent activities and any volunteer work for which any form of monetary or in-kind
compensation was received. Passive investment in any public traded business is not a required reporting
item.
4. Direct Deposit Information The Department of the Treasury requires all Federal payments be made by electronic funds transfer (EFT),
also called Direct Deposit. If you have not previously signed up to receive compensation with EFT, or desire
to change your current account information, please submit SF-1199A, Direct Deposit Sign Up. If you do not
have a bank account, you may be required to receive your payment through Direct Express Debit
MasterCard. To request information on the Direct Express Debit MasterCard, go to www.usdirectexpress.
com or call 1-800-333-1795. If directed to enroll in the Program, you may contact the Department of the
Treasury at 1-888-224-2950 to address any questions or concerns you may have, as well as apply for a
waiver from the process. NOTE: payments to residents of foreign countries are exempt from the Treasury
requirements.
The authority for requesting this information is 5 U.S.C. 8101 et seq. The information will be used to determine entitlement to benefits.
Furnishing the requested information is required for the claimant to obtain or retain a benefit. Information collected will be handled and
stored in compliance with the Freedom of Information Act, the Privacy Act of 1974, as amended (5 U.S.C.552a). Failure to furnish the
requested information may delay the process, or result in an unfavorable decision or a reduced benefit.
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 13
minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and
completing and reviewing the collection of information. The obligation to respond to this collection is voluntary (5 U.S.C. 8101 et seq.) to
obtain or retain a benefit. Send comments regarding the burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the Office of Workers' Compensation Programs, U.S. Department of Labor, Room S3229, 200
Constitution Avenue, N.W.,Washington, D.C. 20210, and reference the OMB Control Number 1240-0046. Note: Do not submit the
completed claim form to this address.
Privacy Act
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees'
Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation
Programs of the U. S. Department of Labor, which receives and maintains personal information on claimants and their immediate
families. (2) Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the
FECA, and may be verified through computer matches or other appropriate means. (3) Information may be given 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. (4) Information may also be given 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. (5) Information may be disclosed 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. (6) Information may be given 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. (7) Disclosure of the claimant's social security number (SSN) or tax identifying
number (TIN) on this form is mandatory. The SSN and/or TIN, and other information maintained by the Office, may be used for
identification, to support debt collection efforts carried on by the Federal government, to verify earnings without further written
authorization, and for other purposes required or authorized by law. (8) Failure to disclose all requested information may delay the
processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.
Note: This notice applies to all forms requesting information that you might receive from the Office in connection with the
processing and adjudication of the claim you filed under the FECA.
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