Claim For Compensation - United States Department Of Labor Page 3
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4INSTRUCTIONS 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.
Requests for Disability-Related Assistance (Forms and Notices):
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from the
OWCP, DFEC in the form of communication assistance, accommodation(s) and/or modification(s) to aid you in the FECA 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 account for the limitations of 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.
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
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.
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
5. List your dependents
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
A third party is an individual or organization (other than the injured employee or the Federal government)
made against 3rd party?
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.
8. Additional Pay
''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.
If the injury was not a traumatic injury reported on Form CA-1, this item does not apply.
11. Continuation of pay (COP)
received
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
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