DOL Form CA-5 2016-2025 free printable template
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ResetPrintClaim for Compensation by
Surviving Spouse and/or ChildrenU.S. Department of LaborOffice of Workers' Compensation Programs2. Date of Birth
(Mo., day, year)1. Name of deceased employee
(Last,
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How to fill out ca 5 form 2016-2025
How to fill out DOL Form CA-5
01
Obtain a blank DOL Form CA-5 from the official website or your employer.
02
Fill in the employee's personal information including name, address, and Social Security number at the top of the form.
03
Enter the date of the injury or illness.
04
Describe the nature of the injury or illness in detail.
05
Provide information about the work being performed at the time of injury.
06
Include details about any medical treatment received.
07
Sign and date the form where indicated.
08
Make copies of the completed form for your records.
09
Submit the form to the appropriate authority, typically your employer or the Department of Labor.
Who needs DOL Form CA-5?
01
DOL Form CA-5 is needed by federal employees who have suffered a work-related injury or illness and wish to report it for compensation or benefits.
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What is DOL Form CA-5?
DOL Form CA-5 is a form used by employees to report a claim for compensation benefits under the Federal Employees' Compensation Act (FECA) for job-related injuries or illnesses.
Who is required to file DOL Form CA-5?
DOL Form CA-5 must be filed by federal employees who have sustained a work-related injury or illness and are seeking compensation benefits.
How to fill out DOL Form CA-5?
To fill out DOL Form CA-5, employees must provide personal details, a description of the injury or illness, information about the circumstances surrounding the incident, and any medical treatment received.
What is the purpose of DOL Form CA-5?
The purpose of DOL Form CA-5 is to formally document an employee's claim for compensation due to a work-related injury or illness, facilitating the processing of the claim by the Department of Labor.
What information must be reported on DOL Form CA-5?
The information that must be reported on DOL Form CA-5 includes the employee's personal information, details about the injury or illness, the date and location of the incident, descriptions of any witnesses, and medical treatment received.
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