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?
U.S. Department of Labor Employment Standards Administration Claim for Compensation Office of Workers' Compensation Programs SECTION I EMPLOYEE PORTION a. Name of Employee Last First Middle OMB No.: 1215-0103 Expires: 08/31/2005
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