Transcription of Claim for Compensation U.S. Department of Labor - DOL
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Claim for Compensation U.S. Department of Labor - DOL
Department of Labor office of Workers' Compensation ProgramsClaim for CompensationSECTION 1 EMPLOYEE PORTIONM iddleOMB No. 1240-0046 Expires: 05/31/2024 First 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 3 Leave without payLeave buy backOther wage loss; specify type, such as downgrade, loss of night differential, :SECTION 2 FromIntermittent?ToIf intermittent, complete Form CA-7a, Time Analysis SheetSchedule Award (Go to Section 4) 3 You must report any and all earnings from employment (outside your federal job); include any employment for which you received a salary, wages, income, sales commissions, or payment of any kind during the period(s) claimed in Section 2.
Office of Workers' Compensation Programs. Claim for Compensation. SECTION 1. EMPLOYEE PORTION. Middle. OMB No. 1240-0046 Expires: 05/31/2024 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 Address (Optional ...
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