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Federal Workers’ Compensation: Filling Out the Form CA-7 Claim for Compensation Form CA-7, Claim for Compensation: This form is used by a federal employee to claim compensation for employment-related disability. The form must be filed with one's employing agency. The purpose of Form CA-7 is to request compensation for: A. Leave Without Pay You can request leave without pay so you do not lose your job while healing. It is better to be on Federal Workers’ Compensation payments: 75% with dependents • 67% without dependents. B. Leave Buy Back You can buy back leave you used while off work due to your injury. C. Other Wage Loss The Difference in wages, because your injury required a down- grade. Losing overtime pay, etc. D. Scheduled Award Payment for a permanent impairment from a work-related injury. You must attach a physician’s medical opinion report based upon the American Medical Association’s, Guides to the Evaluation of Permanent Impairment, 6 th Edition and all of the Office of Workers’ Compensation Program's filing requirements. How to submit your Form CA-7: 1. If you’re still employed with the agency where you were injured: • Complete your portion of Form CA-7. • Electronically file with PDF’s of medical reports and/or documents. • Paper: Give the CA-7, documents and medical reports to your supervisor. 2. If no longer employed at the agency where you were injured: • Electronically & Paper: Send directly to the U.S. Department of Labor. 3. Schedule Awards - Request payment for permanent impairment. • Electronically & Paper: Send directly to the U.S. Department of Labor with medical report rating your injuries. Form CA-7, Page 2 Employee: For the first Form CA-7 claim sent, complete sections 8 through 15. Supervisor: For subsequent claims, your supervisor is to complete sections 12 through 15 only. Form CA-7, Page 3: Instructions for Completing Form CA-7 This is the instructions page for filling out Form CA-7. Form CA-7 Page 4 - Privacy Notice This page outlines the Government's Privacy Act. Form CA-7 Description Form CA-7 Purpose Form CA-7 Submitting Form CA-7, Page 2 Form CA-7, Page 3 Form CA-7, Page 4 5100 N. Brookline Ave. #465 Oklahoma City, OK 73112 (405) 917-5336 Fax: (405) 917-2250 EllisClinic.com

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Page 1: )HGHUDO :RUNHUV¶ &RPSHQVDWLRQ )LOOLQJ 2XW WKH …

Federal Workers’ Compensation: Filling Out the Form CA-7Claim for Compensation

Form CA-7, Claim for Compensation: This form is used by afederal employee to claim compensation for employment-relateddisability. The form must be filed with one's employing agency.

The purpose of Form CA-7 is to request compensation for: A. Leave Without PayYou can request leave without pay so you do not lose your jobwhile healing. It is better to be on Federal Workers’ Compensationpayments: 75% with dependents • 67% without dependents.

B. Leave Buy BackYou can buy back leave you used while off work due to your injury.

C. Other Wage LossThe Difference in wages, because your injury required a down-grade. Losing overtime pay, etc.

D. Scheduled AwardPayment for a permanent impairment from a work-related injury.You must attach a physician’s medical opinion report basedupon the American Medical Association’s, Guides to the Evaluationof Permanent Impairment, 6th Edition and all of the Office ofWorkers’ Compensation Program's filing requirements.

How to submit your Form CA-7: 1. If you’re still employed with the agency where you were injured: • Complete your portion of Form CA-7. • Electronically file with PDF’s of medical reports and/or documents. • Paper: Give the CA-7, documents and medical reports to your supervisor.

2. If no longer employed at the agency where you were injured: • Electronically & Paper: Send directly to the U.S. Department of Labor.

3. Schedule Awards - Request payment for permanent impairment. • Electronically & Paper: Send directly to the U.S. Department of Labor with medical report rating your injuries.

Form CA-7, Page 2Employee:For the first Form CA-7 claim sent, complete sections 8 through 15.

Supervisor:For subsequent claims, your supervisor is to complete sections12 through 15 only.

Form CA-7, Page 3: Instructions for Completing Form CA-7This is the instructions page for filling out Form CA-7.

Form CA-7 Page 4 - Privacy NoticeThis page outlines the Government's Privacy Act.

Form CA-7 Description

Form CA-7 Purpose

Form CA-7 Submitting

Form CA-7, Page 2

Form CA-7, Page 3

Form CA-7, Page 4

5100 N. Brookline Ave. #465 Oklahoma City, OK 73112(405) 917-5336 Fax: (405) 917-2250 EllisClinic.com