DOL Form CA-5 1997 free printable template
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Reset Print Claim for Compensation by Widow, Widower, and/or Children U.S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs OMB No. 1215-0155 Expires:
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How to fill out DOL Form CA-5
01
Obtain a copy of DOL Form CA-5 from the Department of Labor website or your employer.
02
Carefully read the instructions provided on the form.
03
Fill out your personal information, including your name, date of birth, and address in the designated fields.
04
Provide details about the injury or illness, including the date it occurred and a description of what happened.
05
Include information about your employer, such as the name and address of your workplace.
06
If applicable, provide information about any witnesses to the incident.
07
Indicate whether you have received any medical treatment for the injury or illness and provide relevant details.
08
Sign and date the form to certify that the information provided is accurate.
09
Submit the completed form to your employer or directly to the Department of Labor, as instructed.
Who needs DOL Form CA-5?
01
DOL Form CA-5 is required for federal employees who have suffered a work-related injury or illness and need to claim compensation.
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What is DOL Form CA-5?
DOL Form CA-5 is a form used to report a claim for compensation under the Federal Employees' Compensation Act (FECA) when an employee suffers a traumatic 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 duty.
How to fill out DOL Form CA-5?
To fill out DOL Form CA-5, the injured employee must provide their personal information, details of the injury, the circumstances surrounding it, and medical information if applicable.
What is the purpose of DOL Form CA-5?
The purpose of DOL Form CA-5 is to formally document traumatic injuries and initiate the process for compensation claims under the FECA.
What information must be reported on DOL Form CA-5?
DOL Form CA-5 must include information such as the date and time of the injury, the location of the incident, a description of how the injury occurred, and any medical care received.
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