Transcription of CA-7, Claim for Compensation Benefits
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CA-7, Claim for Compensation Benefits
Department of LaborEmployment Standards AdministrationClaim for CompensationOffice of Workers' Compensation ProgramsEMPLOYEE PORTIONSECTION IMiddleOMB No.:1215-0103 FirstLasta. Name of EmployeeExpires:08/31/2005c. OWCP File Numberb. Mailing Address (Including City, state, ZIP Code)d. Date of Injurye. Social Security NumberMonth Day Yearf. Telephone 2 Compensation is claimed for:Inclusive Date Range-TOIntermittent?From-Go to Section 3Go to Section 3, and Complete Form CA-7bGo to Section without payYesLeave buy wage loss; ofsuch as downgrade,night differential, intermittent, complete Form CA-7a,Time Analysis SheetType:Schedule Award (Go to Section 4) period(s) claimed in Section 2?SECTION 3 Have you worked outside your federal jobduring(include salaried, self-employed, commissioned, volunteer, etc.)YesName and Address of BusinessCityZIP CodeAddressStateNameNoGo toDates Worked:Type of Work:Section 4 SECTION 4 Complete Sections 5 through 7 and a Form SF- 1 199A, "Direct Deposit Sign-up"YesNoHas there been any change in your dependents, or has your direct deposit information changed, or has there been a claimfiled with Civil Service Retirement, another federal retirement or disability law, or with the Department of VeteransAffairs since your last CA-7 Claim ?
Employing Agency Portion For first CA-7 claim sent, complete sections 8 through 15. For subsequent claims, complete sections 12 through 15 only.
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