Fillable Form CA-7 (2018)

What is the CA-7 Form?

The CA-7 Form, formally known as Claim for Compensation Form, is released by the U.S. Department of Labor for employees and employers to settle compensation claims for injuries suffered while on the job or those with occupational disease during the performance of work-related duties.

How to fill out the CA-7 Form?

Section 1- Employee Portion
a. Name of Employee
Enter your last, first, and middle name on the space provided.

b. Mailing Address
Provide the city, state, zip code, and your complete mailing address.

c. OWCP File Number
Provide the OWCP file number on the space provided.

d. Date of Injury
Enter the date of injury.

e. Social Security Number
Provide your SSN.

f. Telephone No./FAX No.
Enter your telephone number or fax number.

g. Email Address
Provide your email address, but this is optional.

Section 2- Compensation is claimed for

Select the appropriate choice (Leave without Pay, Leave buy back, Other wage loss, Schedule Award), enter the inclusive date range on the space provided, and identify if intermittent.

If you select “Other Wage Loss”, specify the type on the space provided.

If you select “Schedule Award”, skip to Section 4.

Section 3- Have you worked outside your federal job for the period(s) claimed in Section 2?
Select Yes if you have worked outside your federal job for the period (s) you’ve entered in Section 2. If not, select No.

Name and Address of Business
If you select “Yes”, provide the name and address of the business including city, state, and zip code of the business you worked for.

Dates Worked
Enter the dates you worked

Type of Work
Provide the type of work you have done.

Section 4
Is this the first CA-7 claim for compensation you have filed for this injury?
If this is the first CA-7 claim for compensation you have filed for your injury, select “Yes” and go to Sections 5 to 7 and Form SF-1199A. If not, select “No” and if you have filed changes to dependent status, direct deposit information, or filed a claim with the US Civil Service Retirement or another federal law or disability law, or with Department of Veteran affairs, select “Yes” and complete Sections 5 to 7 and Form SF-1199A. Otherwise, select “No” and go to Section 7.

Section 5
List your dependents (including spouse).
Provide the required information of your dependents and spouse on the space provided.

Name
Provide the name of your dependent or spouse.

Social Security #
Provide the SSN of your dependent or spouse.

Date of Birth
Provide the date of birth of your dependent or spouse.

Relationship
Enter your relationship with the dependent.

Living with you?
Select “Yes” if your dependent or spouse is living with you. If not, select “No” and answer lines a and b.

a. Are you making support payments for a dependent noted above or on your attachments?
Select “Yes” if you are making support payments for a dependent and provide the name and address where your support payments are made. If not, select “No”.

b. Were support payments ordered by a court?
If the support payments were ordered by a court, select “Yes” and attach a copy of the court of order. If not, select “No”.

Section 6
a. Was/will there be a claim made against a 3rd party?
Select “Yes” if there was or there will be a claim made against a third party. If none, select “Yes”.

b. Have you ever applied for/received disability benefits from the Department of Veteran Affairs?
If you have applied for or received disability benefits from the Department of Veteran Affairs, select “Yes” and provide the Claim Number, Full Address of VA Office where claim is filed, Nature of Disability, and Monthly Payment on the space provided. If not, select “No”.

c. Have you applied for/received payment under any Federal Retirement or Disability Law?
If you have applied for or received payment under any Federal Retirement or Disability Law, select “Yes” and provide the Claim Number, Date Annuity Began, and Amount of Monthly Payment on the space provided. Identify the retirement system by selecting any of the choices (CSRS, FERS, SSA, or Other).

If you have not applied for or received payment under any Federal Retirement or Disability Law, select “No”.

Section 7
Employee’s Signature
Provide the signature of the employee.

Date
Enter the date the employee signed and completed the form.

Section 8 to 15 - This section is to be filled by the employing agency.

Section 8
Enter the details on the date of the employee’s injury, base pay, and additional pay. Provide the same details for the section on when the employee stopped working.

Section 9
a. Does employee worked a fixed 40-hour per week schedule?
If the employee worked a fixed 40-hour per week schedule, select “Yes”. If not, select “No”.

If you select “Yes”, encircle the scheduled days. If not, enter the scheduled hours on the space provided.

b. Did employee work in position for 11 months prior to injury?
If the employee worked in position for 11 months prior to the injury, select “Yes”. If not, select “No”.

Section 10
a. On date pay stopped, was employee enrolled in Health Benefits under the FEHBP?
Select “Yes” if the employee was enrolled in Health Benefits under the FEHBP and enter the Code on the space provided. If not, select “No”.

b. On date pay stopped, was employee enrolled in Basic Life Insurance?
Select “Yes” if the employee was enrolled in Basic Life Insurance. If not, select “No”.

c. On date pay stopped, was employee enrolled in Optional Life Insurance?
Select “Yes” if the employee was enrolled in Optional Life Insurance and enter the Class on the space provided. If not, select “No”.

d. On date pay stopped, was employee enrolled in a Retirement System?
Select “Yes” if the employee was enrolled in a Retirement System and enter the Plan on the space provided. If not, select “No”.

Section 11
Continuation of Pay Received
Provide the start date and end date on the space provided.

Intermittent
If intermittent, select “Yes”. If not, select “No”.

Section 12
Show pay status and inclusive dates for period(s) claimed
Sick Leave
Enter the inclusive dates for sick leave.

Annual Leave
Enter the inclusive dates for annual leave.

Leave Without Pay
Enter the inclusive dates for leave without pay.

Work
Enter the inclusive dates for work.

Section 13
Did employee return to work?
If the employee returned to work, select “Yes” and provide the date the employee returned. If not, select “No”.

If returned, did employee return to the pre-date-of-injury job, with the same number of hours and the same duties?
Select “Yes” if the employee returned to the pre-date-of-injury job with the same number of hours and the same duties. If not, select “No” and explain on the space provided.

Section 14
Remarks
Use this space to provide additional remarks.

Section 15
Signature
Provide your signature representing the agency.

Title
Provide your title.

Date
Enter the date you completed and signed the form.

Name of Agency
Provide the name of the agency.

Date Claim Form Received from Employee
Enter the date you received the claim form from the employee.

If OWCP needs specific pay information, the person who should be contacted is:
Name
Provide the name of the contact.

Title
Provide the title of the contact person.

Telephone No.
Provide the telephone number of the contact person.

Fax No.
Provide the fax number of the contact person.

Email Address
Enter the email address of the contact person.

Submission

Your agency or company must complete their portion of the CA-7 and submit it with the medical documentation to the Office of Workers' Compensation Programs office.