Form Ca 7 – Fill Out and Use This PDF

The CA-7 Form, issued by the U.S. Department of Labor's Office of Workers' Compensation Programs, serves as a Claim for Compensation. This essential document is designed for employees seeking compensation for lost wages due to work-related injury or disease. With sections dedicated to personal information, type of wage loss claimed, employment outside the federal job, and dependent information, completing this form accurately is crucial for the compensation process. Click the button below to start filling out your CA-7 form today.

Get Form Now Download PDF

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.

Question	Answer
Form Name	Form Ca 7
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	ca 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

Intermittent?

Yes

Leave without pay

Go to Section 3

Leave buy back

Yes

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

Other wage loss; specify type,

Yes

Go to Section 3

such as downgrade, loss of

night differential, etc.

Type:

If intermittent, complete Form CA-7a,

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

Go to section 4

SECTION 4

Yes

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

If Yes, support payments are made to:

Name

Address

City

State

ZIP Code

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

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

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

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

Employing Agency Portion

For first CA-7 claim sent, complete sections 8 through 15.

For subsequent claims, complete sections 12 through 15 only.

SECTION 8

Show Pay Rate as of

Additional Pay

Date of Injury:

Base Pay

Type

Date:

per

Grade:

Step:

Date Employee Stopped Work:

Type

Date:

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

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

T W TH F

WEEK 1

From

5/14

5/20

From

WEEK

WEEK 2

5/21

5/27

From

b. Did employee work in position for 11 months prior to injury?

Yes

If No, would position have afforded employment for 11 months but for the injury?

Yes

SECTION 10 On date pay stopped, was employee enrolled in:

a. Health Benefits under

Yes

Code

c. Optional Use Insurance?

Yes

Class

the FEHBP?

d. A Retirement System?

Yes

Plan

(D-Z only)

b. Basic Life Insurance?

Yes

(Specify CSRS, FERS, Other)

SECTION 11 Continuation of Pay (COP) Received (Show inclusive dates):

Yes

Complete Time

Intermittent?

Analysis Sheet, Form CA-7a

From

SECTION 12 Show pay status and inclusive dates for period(s) claimed:

Intermittent?

Sick Leave From

Yes

If intermittent, complete Form

Annual Leave From

Yes

CA-7a, Time Analysis

Sheet.

Leave without Pay From

Yes

If leave buy back, also submit

Work From

Yes

completed Form CA-7b.

SECTION 13 Did employee return to work?

Yes

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

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 Recieved from Employee

If OWCP needs specific pay information, the person who should be contacted is:

Name

Title

Telephone No.

(

)

Fax No.

(

)

E-Mail Address

INSTRUCTIONS FOR COMPLETING FORM CA-7

If the employee does not quality for continuation of pay (for 45 days), the form should be completed and filed with the OWCP as soon as pay stops. The form should also be submitted when the employee reaches maximum improvement and claims a schedule award. If the employee is receiving continuation of pay and will continue to be disabled after 45 days, the form should be filed with OWCP 5 working days prior to the end of the 45-day period.

The CA-7 also should be used to claim continuing compensation, when a previous CA-7 claim has been made.

Collection of this information is required to obtain a benefit and is authorized by 20 C.F.R.10.106.

EMPLOYEE (or person acting on the employee's behalf) - Complete sections 1 through 7 as directed and submit the form to the employee's supervisor.

SUPERVISOR (or appropriate official in the employing agency) - Complete sections 8 through 15 as directed and promptly forward the form OWCP.

EXPLANATIONS - Some of the items on the form which may require further clarification are explained below:

Section Number		Explanation

2d. Schedule Award		Schedule awards are paid for permanent impairment to a member or function
		of the body.
5. List your dependents		Your wife or husband is a dependent if he or she is living with you. A child is a
		dependent if he, or she either lives with you or receives support payments from
		you, and he or she: 1) is under 18, or 2) is between 18 and 23 and is a full-time
		student, or 3) is incapable of self-support due to physical or mental disability.

6a. Was/will there be a claim made against 3rd party?

8. Additional Pay

A third party is an individual or organization (other than the injured employee or the Federal government) who is liable for the injury. For instance, the driver of a vehicle causing an accident in which an employee is injured, the owner of a building where unsafe conditions cause an employee to fall, and a manufacturer who gave improper instructions for the use of a chemical to which an employee is exposed, could all be considered third parties to the injury.

''Additional Pay'' includes night differential, Sunday premium, holiday premium, and any other type (such as hazardous duty or ''dirty work'' pay) regularly received by the employee, but does not include pay for overtime. If the amount of such pay varies from pay period to pay period (as in the case of holiday premium or a rotating shift), then the total amount of such pay earned during the year immediately prior to the date of injury or the date the employee stopped work (whichever is greater) should be reported.

11.Continuation of pay (COP) received

14. Remarks

If the injury was not a traumatic injury reported on Form CA-1, this item does not apply.

This space is used to provide relevant information which is not present else- where on the form.

The authority for requesting this information is 5 U.S.C. 8101 et seq. The information will be used to determine entitlement to benefits. Furnishing the requested information is required for the claimant to obtain or retain a benefit. Information collected will be handled and stored in compliance with the Freedom of Information Act, the Privacy Act of 1974, as amended (5 U.S.C. 552a). Failure to furnish the requested information may delay the process, or result in an unfavorable decision or a reduced benefit.

Public Burden Statement

Public reporting burden forth is collection of information is estimated to average 13 minutes per response including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this estimate or any other aspect of this information collection, including suggestions for reducing this burden, please send them to the Department of Labor, Office of Workers' Compensation Programs, Room S-3229, 200 Constitution Avenue, N.W. Washington, D.C. 20210.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE

Privacy Act

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are here by notified that: (1) The Federal Employees' Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' Compensation Programs of the U. S .Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for and the amount of benefits payable under the FECA, and may be verified through computer matches or other appropriate means. (3) Information may be given to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer questions concerning the status of the claim, verify billing, and to consider issues relating to retention, rehire, or other relevant matters. (4) Information may also be given to other Federal agencies, other government entities, and to private-sector agencies and/or employers as part of rehabilitative and other return-to-work programs and services. (5) Information may be disclosed to physicians and other healthcare providers for use in providing treatment or medical/vocational rehabilitation, making evaluations for the Office, and for other purposes related to the medical management of the claim. (6) Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act. (7) Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN, and other information maintained by the Office, may be used for identification, to support debt collection efforts carried on by the Federal government, and for other purposes required or authorized by law. (8) Failure to disclose all requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.

Note: This notice applies to all forms requesting information that you might receive from the Office in connection with the processing and adjudication of The claim you filed under the FECA.

How to Edit Form Ca 7 Online for Free

Through the online PDF editor by FormsPal, it is possible to fill in or alter ca7 form usps right here and now. To keep our editor on the forefront of efficiency, we aim to put into action user-driven features and improvements regularly. We're always looking for feedback - play a vital part in revampimg PDF editing. By taking some simple steps, you may start your PDF journey:

Step 1: Access the PDF in our editor by clicking the "Get Form Button" in the top part of this page.

Step 2: As you start the PDF editor, you will get the form all set to be filled out. Apart from filling in various blank fields, you could also do some other things with the Document, specifically putting on custom text, changing the original textual content, adding graphics, putting your signature on the form, and much more.

Completing this form calls for care for details. Make certain all mandatory fields are completed accurately.

1. The ca7 form usps needs specific information to be inserted. Be sure that the next blanks are filled out:

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.

Part number 2 in filling out department of labor ca 7

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.

Stage no. 4 in completing department of labor ca 7

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.

Filling in segment 5 of department of labor ca 7

People frequently make mistakes when completing Yes in this area. Be certain to read twice everything you type in here.

Step 3: Right after rereading the fields you've filled out, click "Done" and you are all set! Obtain the ca7 form usps when you register here for a free trial. Conveniently get access to the form within your FormsPal account, together with any edits and changes all synced! FormsPal is committed to the personal privacy of our users; we always make sure that all personal information coming through our system stays protected.

Form Ca 7 – Fill Out and Use This PDF

Form Ca 7 PDF Details

Form Preview Example

How to Edit Form Ca 7 Online for Free

Form Ca 7 isn’t the one you’re looking for?

Related Documents