Form CA-278
Rev. March 2017
Page 2 of 2
Instructions for Form CA-278
1. Mail one copy of this form with the attached supporting documents described below to the U.S.
Department of Labor, Office of Workers’ Compensation Programs, 1240 East 9th Street, Room 851,
Cleveland, Ohio 44199, unless otherwise instructed.
2. File a separate form for each employee.
3. Complete every item on the form.
4. Attach supporting documents (i.e., receipts or copies of checks and drafts) that show the benefits paid. In
lieu of the supporting documents, a certificate may be submitted listing benefits paid that includes (1) the
payee, (2) the services rendered, (3) the amount paid, (4) the date paid, (5) the check or draft number,
and (6) the signature of the certifier.
5. List all expenses incurred to the date of submitting the form. Supplemental claims for reimbursement
should be made on separate forms.
6. Indicate whether the benefits paid were for detention, disability, death, etc., and state the basis for paying
the claim (e.g., the nature of the particular war-risk hazard).
7. Mark each receipt or other attachment with:
(a) the case number appearing in the claim
(b) the employee’s name, and
(c) “EXHIBIT” to case to which attributable.
8. Attach papers in support of each case, such as copies of any compensation award, any applicable
contract (or sufficient excerpt), and any applicable insurance policy, marking such supporting papers as
an “EXHIBIT” to the respective case.
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 this information is estimated to average 30 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the date needed, and completing
and reviewing the collection of information. The authority for requesting this information is 42 U.S.C. 1701 et
seq. The information will be used to determine entitlement to benefits. Furnishing the requested information
is voluntary, but failure to provide the requested information may result in denial of the request for
reimbursement. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the U. S. Department of Labor, OWCP, Room
S3229, 200 Constitution Avenue, NW, Washington, D.C., 20210, and reference OMB Control Number
1240-0006. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS.
Request 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.