Search results with tag "Notice of occupational disease"
Evidence Required in Support of a Claim U.S. Department of ...
www.dol.govWhenever an employee wants to file a claim for occupational disease or illness, please give him or her: 1. Form CA-2, Federal Employees' Notice of Occupational Disease and Claim for Compensation, and 2. Two copies of the checklist describing evidence required in support of the claim. One checklist is for the employee to
Notice of Occupational Disease U. S. Department of Labor ...
www.dol.govNotice of Occupational Disease U. S. Department of Labor and Claim for Compensation Office of Workers' Compensation Programs Employee: Please complete all boxes 1 - 18 below. Do not complete shaded areas. Employing Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c.
Notice of Occupational Disease U.S. Department of Labor …
www.dol.govNotice of Occupational Disease and Claim for Compensation. Employee: Please complete all boxes 1 - 18 below. Do not complete shaded areas. Employing Agency (Supervisor or Compensation Specialist): Complete shaded boxes a, b, and c. 1. Name of Employee (Last, First, Middle) 2. Social Security Number. 3. Date of birth Mo. Day Yr. 4. Sex 5. Home ...