Claim for Compensation U.S. Department of Labor
Department of Labor Office of Workers' Compensation ProgramsClaim for CompensationSECTION 1EMPLOYEE PORTIONMiddleOMB No. 1240-0046 Expires: 10-31-2014First a. Name of EmployeeLastc. OWCP File Numberb. mailing address ( Including City State, ZIP Code )d. Date of Injurye. Social Security NumberMonth Day YearE-Mail address (Optional)f. Telephone is claimed for:Inclusive Date RangeGo to Section 3Go to Section 3, and Complete Form CA-7bGo to Section 3Leave without payLeave buy backOther wage loss; specify type, such as downgrade, loss of night differential, :SECTION 2FromIntermittent?ToIf intermittent, complete Form CA-7a, Time Analysis SheetSchedule Award (Go to Section 4) 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.
U.S. Department of Labor Office of Workers' Compensation Programs. Claim for Compensation. SECTION 1. EMPLOYEE PORTION. Middle. OMB No. 1240-0046 Expires: 10-31-2014 a. Name of Employee. Last First . 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 ...
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