Form-Ca-7 - Claim For Compensation Page 2

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Employing 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
Type
Type
Type
Date of Injury:
Base Pay
/
/
per
per
per
per
Date:
$
$
$
$
Grade:
Step:
Date Employee Stopped Work:
Type
Type
Type
/
/
per
per
per
per
$
Date:
$
$
$
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
1. If Yes, circle scheduled days:
S
M
T
W
TH
F
S
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
S
M
T
W
TH
F
S
WEEK 1
WEEK 1
4
8
6
6
From
5/20
5/14
to
From
to
WEEK 2
WEEK
4
8
6
6
5/21
5/27
From
to
From
to
b. Did employee work in position for 11 months prior to injury?
Yes
No
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:
a.
Health Benefits under
c. Optional Use Insurance?
No
Yes
Class
the FEHBP?
No
Yes Code
(D-Z only)
d. A Retirement System?
No
Yes
Plan
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
/
/
/
/
To
Sick Leave From
Yes
No
CA-7a, Time Analysis
/
/
/
/
Annual Leave From
To
Yes
No
Sheet.
/
/
/
/
To
Leave without Pay From
Yes
No
If leave buy back, also submit
/
/
/
/
completed Form CA-7b.
Work From
To
Yes
No
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
If OWCP needs specific pay information, the person who should be contacted is:
Name
Title
(
)
-
Telephone No.
(
)
Fax No.
E-Mail Address

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