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4Employing Agency Portion
For first CA-7 claim sent, complete sections 8 through 15.
For subsequent claims, complete sections 12 through 15 only.
Additional Pay
SECTION 8
Show Pay Rate as of
Additional Pay
Additional Pay
Date of Injury:
Base Pay
Type
Type
Type
$
per
Date:
$
per
$
per
$
per
Grade:
step:
Date Employee Stopped Work:
Type
Type
Type
Date:
$
per
$
per
$
per
$
per
Grade:
step:
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)
SECTION 9
a. Does employee work a fixed 40-hour per week schedule?
Yes
No
S
M
T
W
T
F
S
1. If Yes, circle scheduled days:
2. If No, show scheduled hours for the two week pay period in which work stopped. Circle the day that work stopped.
FOR EXAMPLE ONLY
S
S
M
T
W TH
F
T
F
S
M
W
TH
S
WEEK 1
4
From
To
8
6
6
From
5/20
5/14
to
From
To
WEEK
4
8
6
6
5/21
5/27
From
to
Yes
No
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?
Yes
No
SECTION 10 On date pay stopped, was employee enrolled in:
No
Yes
Class
c. Optional Life Insurance?
a. Health Benefits under
No
Yes
Code
(D-Z only)
the FEHBP?
Plan
d. A Retirement System?
No
Yes
b. Basic Life Insurance?
No
Yes
(Specify CSRS, FERS, Other)
SECTION 11 Continuation of Pay (COP) Received ( Show inclusive dates ):
Yes - Complete Time
Analysis Sheet, Form CA-7a
Intermittent?
From
To
No
SECTION 12 Show pay status and inclusive dates for period(s) claimed:
Intermittent?
If intermittent, complete Form
Sick Leave From
To
Yes
No
CA-7a, Time Analysis Sheet.
Annual Leave From
To
Yes
No
Leave without Pay From
To
Yes
No
If leave buy back, also submit
Work From
To
Yes
No
completed Form CA-7b.
Did employee return to work?
SECTION 13
Yes
No
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?
Yes
No
If No, explain:
SECTION 14
Remarks:
SECTION 15
An employing agency official who knowingly certifies to any false statement, misrepresentation, or concealment of fact,
with respect to this claim may also be subject to appropriate felony 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.
Signature
Title
Date
/
/
(Agency Official)
Name of Agency
Date Claim Form Received from Employee
/
/
If OWCP needs specific pay information, the person who should be contacted is:
Name
Title
Telephone No.
Fax No.
E-Mail Address
CA-7 Page 2 (Rev.05-11)
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