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Federal Workers Compensation Forms

OWCP Workers Compensation Forms

This page links to OWCP forms for Federal Workers Compensation cases. You can download these forms to your computer and then print them from your computer to use for your own OWCP claim. You will need the  Acrobat Reader to open and print these forms. You can download the Adobe Reader using the button below.

Form Number
OWCP Form Title or Description
CA-1 Federal Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation
CA-2 Notice of Occupational Disease and Claim for Compensation
CA-2a Notice of Recurrence
CA-5 Claim for Compensation by Widow, Widower, and/or Children
CA-5b Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren
CA-6 Official Supervisor’s Report of Employee’s Death
CA-7 Claim for Compensation – Form CA-7 replaces ALL prior versions of CA-7 & CA-8 (see FECA Bulletin No. 99-18)
CA-7a Time Analysis Form, used for claiming compensation, including repurchase of paid leave
CA-7b Leave Buy Back (LBB) Worksheet/Certification and Election
CA-10 What A Federal Employee Should Do When Injured At Work
CA-12 Claim For Continuance of Compensation Under the Federal Employees’ Compensation Act
CA-17 Duty Status Report
CA-20 Attending Physician’s Report
CA-35 Evidence Required in Support of a Claim for Occupational Disease
CA-40 Designation of Recipient of FECA Death Gratuity Payment, under Section 1105 of Public Law 110-181 (Section 8102a)
CA-41 Claim for Survivor Benefits Under the Federal Employees’ Compensation Act Section 8102a Death Gratuity
CA-42 Official Notice of Employees’ Death for Purposes of FECA Section 8102a Death Gratuity
CA-278 Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act
CA-721 Notice of Law Enforcement Officer’s Injury Or Occupational Disease
CA-722 Notice of Law Enforcement Officer’s Death
CA-1031 Letter to Dependents to Verify Claimant Support
CA-1074 Letter to Parents in Death Claim Development
CA-1108 Statement of Recovery Letter with Long Form
CA-1122 Statement of Recovery Letter with Short Form
CA-2231 Claim for Reimbursement Assisted Reemployment
OWCP-5a Work Capacity Evaluation Psychiatric/Psychological Conditions
OWCP-5b Work Capacity Evaluation Cardiovascular/Pulmonary Conditions
OWCP-5c Work Capacity Evaluation for Muscular Skeletal Conditions
OWCP-16 Rehabilitation Plan And Award
OWCP-17 Rehabilitation Maintenance Certificate
OWCP-20 Overpayment Recovery Questionnaire
OWCP-44 Rehabilitation Action Report
OWCP-04 Uniform Billing Form
OWCP-915 Claim For Medical Reimbursement Form OWCP-915 replaces CA-915
OWCP-957 Medical Travel Refund Request
OWCP-1168 Provider Enrollment form
OWCP-1500 Health Insurance Claim Form
HCFA-1500 Health Insurance Claim Form