Owcp Claim Status - Branch 38
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1OWCP File No.
U.S. Postal Service
REQUEST - OWCP CLAIM STATUS
Instructions
To:
A.
Postmaster: Enter File No. and complete Section A. Check re-
OFFICE OF WORKERS COMPENSATION PROGRAMS
quest boxes in Section B as needed (1-5). Forward to OWCP
UNITED STATES DEPARTMENT OF LABOR
District Office in duplicate.
OWCP Office: The employee below has filed a claim with you.
B.
Please help us determine this claimant's status by completing
Section B as checked (1-5). Sign, date and return copy to Re-
quester.
Claimant
Requester
Name:
Name:
Work Address:
Address:
Date:
Date Injured:
This is restricted information and is used only for official Postal Service purposes.
# #
a. Accepted (Date) _______________________
# #
# #
1
.
Claim for Benefits is:
b. Rejected (Date) _______________________
# #
c. Pending
# #
Yes (Complete Item 3.)
# #
Employee is Currently
2.
# #
Receiving Compensation:
No
# #
a. Temporary Total Disability of
$_____________ per ________________.
# #
b. Permanent Total Disability of
$_____________ per ________________.
# #
# #
3
.
Type/Amount of Payment:
c. Loss of Wage Earning Capacity of
$_____________ per ________________.
# #
d. Scheduled Award of
$_____________ per ________________.
Terminates (Date) _____________________
# #
4
.
Last Medical Examination (Date) :
_____________________ (Attach Copy)
# #
5
Other (Specify) :
.
Signature and Title (OWCP Officer)
Date
2573,
PS Form
June 1991
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