Claim For Compensation - United States Department Of Labor

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U.S. Department of Labor

Claim for Compensation

Office of Workers' Compensation Programs

SECTION 1

EMPLOYEE PORTION

a. Name of Employee

Last

First

Middle

OMB No. 1240-0046

Expires: 01-31-2018

b. Mailing Address ( Including City State, ZIP Code )

c. OWCP File Number

d. Date of Injury

e. Social Security Number

Month Day Year

E-Mail Address (Optional)

f. Telephone No./FAX No.

SECTION 2

Compensation is claimed for:

Inclusive Date Range

From

Intermittent?

Leave without pay

Yes

Go to Section 3

Leave buy back

Yes

Go to Section 3, and Complete Form CA-7b

Other wage loss; specify type,

Yes

Go to Section 3

such as downgrade, loss of

Type:

night differential, etc.

If intermittent, complete Form CA-7a,

Time Analysis Sheet

Schedule Award (Go to Section 4)

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:

Yes

Name

Address

City

State

ZIP Code

Go to

section 4

Dates Worked:

Type of Work:

SECTION 4

Is this the first CA-7 claim for compensation you have filed for this injury?

Yes

Complete Sections 5 through 7 and a Form SF-1199A, "Direct Deposit Sign-up"

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.

Yes

- Complete Sections 5 through 7 or a new SF-1199A to reflect change(s)

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?

Name

Social Security #

Date of Birth

Relationship

Yes No

For dependents not living

with you complete items

a and b below. ,

Are you making support payments for a dependent noted above or on your attachment(s)?

Yes

If Yes, support payments are made to:

Name

Address

City

State

ZIP Code

b. Were support payments ordered by a court?

Yes

If Yes, attach copy of court order.

SECTION 6

a. Was/Will there be a claim made against a 3rd party?

Yes

b. Have you ever applied for or received disability benefits from the Department of Veterans Affairs?

Nature of Disability and Monthly Payment

Yes

Full Address of VA Office Where Claim Filed

Claim Number

c. Have you applied for or received payment under any Federal Retirement or Disability law?

Yes

Claim Number

Date Annuity Began

Amount of Monthly Payment

Retirement System (CSRS, FERS, SSA, Other)

CSRS

FERS

SSA

Other

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.

Employee's Signature

Date ( Mo., day, year)

If you have a disability (a substantially limiting physical or mental impairment), contact OWCP for information on communication assistance (alternate formats or sign language

interpretation), accommodations and/or modifications. See Instructions for Disability-Related Assistance under Federal disability nondiscrimination law.