Form Ca 7 PDF Details

Ensuring workers are supported during times of injury or illness as a result of their duties is a fundamental aspect of employment, especially within federal jobs. The CA-7 form, provided by the U.S. Department of Labor's Office of Workers' Compensation Programs, plays a pivotal role in this support system. This form aids employees in claiming compensation benefits, covering areas such as leave without pay, leave buyback, and other wage loss scenarios. It meticulously guides the employee through reporting outside earnings, dependent changes, or alterations in direct deposit information. Furthermore, it addresses potential third-party claims, as well as inquiries into any other federal retirement or disability benefits the employee might be receiving or eligible for. Each section is designed to ensure both the employee and employing agency provide detailed and accurate information, from personal identification to specifics about the injury and its impact on the employee’s work capacity. The form also emphasizes the serious repercussions of fraudulent claims, highlighting the importance of truthfulness and accuracy in the pursuit of compensation. By threading through these various components, the CA-7 form exemplifies a vital resource for federal employees seeking support following a workplace injury or illness.

QuestionAnswer
Form NameForm Ca 7
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesca 7 form post office, ca7 form, ca7 form ca, ca7a form

Form Preview Example

Date (Mo., day, year)

Claim for Compensation

 

 

 

U.S. Department of Labor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employment Standards Administration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office of Workers' Compensation Programs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 1

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEE PORTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Name of Employee

Last

 

First

 

 

 

 

 

 

 

 

Middle

OMB No.

 

1215-0103

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Expires:

 

10/31/2008

 

 

 

 

b. Mailing Address (Including City State, ZIP Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. OWCP File Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Date of Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-Mail Address (Optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 2 Compensation is claimed for:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f. Telephone No./FAX No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Inclusive Date Range

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

From

To

 

 

Intermittent?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

 

Leave without pay

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Go to Section 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

 

Leave buy back

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

No

 

Go to Section 3, and Complete Form CA-7b

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

 

Other wage loss; specify type,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

No

 

Go to Section 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

such as downgrade, loss of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

night differential, etc.

 

 

 

Type:

 

 

 

 

 

 

 

 

 

 

 

If intermittent, complete Form CA-7a,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d.

 

Schedule Award (Go to Section 4)

 

 

 

 

Time Analysis Sheet

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 3 You must report all earnings from employment (outside your federal job); include any employment for which you received a salary, wages, income, sales commissions, piecework, or payment of any kind during the period(s) claimed in Section 2. Include self-employment, involvement

in business enterprises, as well as service with the military forces. Fraudulent concealment of employment or failure to report income may result in forfeiture of compensation benefits and/or criminal prosecution. Have you worked outside your federal job for the period(s) claimed in Section 2?

Yes

No

Go to section 4

SECTION 4

Yes

No

Name and Address of Business:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

Address

 

 

City

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates Worked:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Work:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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"

Has there been any change in your dependents, or has your direct deposit information changed, or has there been a claim 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

SECTION 5

 

List your dependents (including spouse):

 

 

 

 

Date of Birth

 

 

Relationship

Living with you?

 

 

 

 

 

Name

 

 

 

 

 

Social Security #

 

 

 

 

 

 

 

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

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

ZIP Code

 

b. Were support payments ordered by a court?

 

Yes

No

 

 

 

 

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?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

Claim Number

Full Address of VA Office Where Claim Filed

 

 

 

 

 

 

Nature of Disability and Monthly Payment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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)

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CSRS

 

FERS

 

SSA

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Form CA-7

Rev. June 2005

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Writing part 1 in department of labor ca 7

2. The next step would be to submit the following fields: SECTION, Yes, Dates Worked Is this the first CA, Complete Sections through and a, your last CA claim, Yes Complete Sections through, No Complete Section, SECTION, Name, List your dependents including, Social Security, Date of Birth, Relationship, Living with you, and Yes No.

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3. Throughout this step, review Any person who knowingly makes any, result in termination of all, Employees Signature, Date Mo day year, and Form CA Rev June. All these will have to be completed with utmost accuracy.

Employees Signature, Form CA Rev June, and Date Mo day year of department of labor ca 7

4. The subsequent section requires your input in the subsequent areas: SECTION, Date of Injury, Show Pay Rate as of, Base Pay, Additional Pay Type, Additional Pay, Type, Additional Pay Type, Date, Grade Date Employee Stopped Work, Step, Date, per, per, and Type. Be sure you fill out all required information to go onward.

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5. The pdf should be concluded with this particular part. Further you will see an extensive listing of blanks that require specific details for your form usage to be complete: b Did employee work in position, Yes, If No would position have afforded, Yes, On date pay stopped was employee, SECTION a, Health Benefits under the FEHBP, b Basic Life Insurance, Yes Code, Yes, c Optional Use Insurance, d A Retirement System, Yes Class, Yes Plan, and DZ only.

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