Form-Ca-7 - Claim For Compensation
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U.S. Department of Labor
Claim for Compensation
Employment Standards Administration
Office of Workers' Compensation Programs
SECTION 1
EMPLOYEE PORTION
Last
First
Middle
OMB No.
1215-0103
a. Name of Employee
Expires:
08/31/2005
c. OWCP File Number
b. Mailing Address (Including City State, ZIP Code)
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
To
Intermittent?
(
)
Yes
No
Go to Section 3
Leave without pay
a.
Yes
Go to Section 3, and Complete Form CA-7b
Leave buy back
No
b.
No
Other wage loss; specify type,
Yes
Go to Section 3
c.
such as downgrade, loss of
Type:
If intermittent, complete Form CA-7a,
night differential, etc.
Time Analysis Sheet
Schedule Award (Go to Section 4)
d.
Have you worked outside your federal job during the period(s) claimed in Section 2?
SECTION 3
(Include salaried, self-employed, commission, volunteer, etc.)
Name and Address of Business:
Yes
Address
Name
City
State
ZIP Code
No
Go to
Type of Work:
section 4
Dates Worked:
SECTION 4
Is this the first CA-7 claim for compensation you have filed for this injury?
Complete Sections 5 through 7 and a Form SF-1199A, "Direct Deposit Sign-up"
Yes
Has there been any change in your dependents, or has your direct deposit information changed, or has there been a claim
No
filed with U.S. Civil Service Retirement, another federal retirement or disability law, or with the Department of Veterans
Affairs since your last CA-7 claim?
Yes - Complete Sections 5 through 7 or a new SF-1199A to reflect change(s)
No - Complete Section 7
List your dependents (including spouse):
SECTION 5
Living with you?
Name
Social Security #
Date of Birth
Relationship
Yes No
/
/
For dependents not
/
/
living with you, complete
items a and b below.
/
/
a. Are you making support payments for a dependent shown above?
Yes
No
If Yes, support payments are made to:
Name
ZIP Code
Address
City
State
No
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
No
b. Have you ever applied for or received disability benefits from the Department of Veterans Affairs?
Claim Number
Full Address of VA Office Where Claim Filed
Nature of Disability and Monthly Payment
Yes
No
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
No
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 felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or
imprisonment, or both. In addition, a felony conviction will result in termination of all current and future FECA benefits.
Employee's Signature
Date (Mo., day, year)
Form CA-7
Rev. Nov. 1999
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