DOL Form CA-5 2013 free printable template
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ResetPrintClaim for Compensation by Widow,
Widower, and/or Children
1. Name of deceased employee (Last, first, middle)U.S. Department of LaborOffice of Workers' Compensation Programs2. Date of Birth
(Mo.,
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How to fill out DOL Form CA-5
How to fill out DOL Form CA-5
01
Begin by obtaining the DOL Form CA-5, which can be downloaded from the U.S. Department of Labor website.
02
At the top of the form, write the claimant's name, contact information, and the date of the injury or illness.
03
Provide details about the work-related injury or illness, including the nature of the injury and where it occurred.
04
Complete the sections regarding the medical treatment received, including the names of healthcare providers and dates of visits.
05
Fill out the section detailing any other benefits received, such as state workers' compensation or other insurance.
06
Review the form for completeness and accuracy to ensure all relevant information is included.
07
Sign and date the form to certify that the information provided is true to the best of your knowledge.
08
Submit the completed form to the appropriate office as indicated in the instructions.
Who needs DOL Form CA-5?
01
DOL Form CA-5 is needed by federal employees who have sustained work-related injuries or illnesses and are seeking to claim benefits under the Federal Employees' Compensation Act (FECA).
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What is DOL Form CA-5?
DOL Form CA-5 is a form used to report an employee's claim for traumatic injury and to document the nature and extent of the injury.
Who is required to file DOL Form CA-5?
DOL Form CA-5 must be filed by federal employees who sustain a traumatic injury while in the performance of their duties.
How to fill out DOL Form CA-5?
To fill out DOL Form CA-5, provide clear and detailed information about the injury, including the date, time, and circumstances of the incident, along with any medical treatment received.
What is the purpose of DOL Form CA-5?
The purpose of DOL Form CA-5 is to document the facts surrounding a federal employee's traumatic injury and to initiate the process for claiming workers' compensation benefits.
What information must be reported on DOL Form CA-5?
Information that must be reported on DOL Form CA-5 includes details about the employee, the injury, the date and place of occurrence, and any medical treatment or diagnosis related to the injury.
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