Transcription of Claim for Compensation U.S. Department of Labor …
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Claim for Compensation U.S. Department of Labor …
Reset Print Claim for Compensation 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: 09/30/2011. 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. Inclusive Date Range ( ) - From To Intermittent? ( ). a. Leave without pay Yes No Go to section 3. b. Leave buy back Yes No Go to section 3, and Complete Form CA-7b c. Other wage loss; specify type, Yes No Go to section 3. such as downgrade, loss of night differential, etc. Type: If intermittent, complete Form CA-7a, d. 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.
U.S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs Claim for Compensation SECTION 1 EMPLOYEE PORTION a. Name of Employee Last First Middle OMB No. 1215-0103
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