Fillable Form CA-7a
CA-7a is a form used to claim FECA compensation when an employee is disabled due to a work-related injury and loses more than three calendar days worth of pay.
What is Form CA-7a?
Form CA 7a, Time Analysis Form, is a form issued by the Department of Labor as a part of the Form CA - 7 series which serves as documents that can be used by workers in claiming compensations that their employers owe them. The CA-7a Form, specifically, deals with the claiming of Federal Employees’ Compensation Act (FECA) compensations.
The Federal Employees Compensation Act is an act that provides coverage for people who had sustained work-related injury and disease. The FECA does this by providing monetary and medical benefits to the worker as well as some assistance in returning to employment. Monetary benefits are either lost wages or payments for the impairment of the worker. Medical benefits are reasonable amounts of medical bills for the injury and disease that the Office of Worker’s Compensation Programs (OWCP) decides are likely to be cured, or relieved to lessen the period of disability. Rehabilitation and physical therapy can also be provided alongside the job placement of the injured.
The CA 7a Form is a document that assists in this regard as Form CA7a is used to claim the monetary benefit in the form of repurchasing their lost wages. This monetary benefit that the CA7a Form helps claim is the wages that were lost due to the leave of absence caused by their injury. Form CA 7a should be used to claim FECA compensation for more than one consecutive period of leave caused by work-related injury or disease.
FECA also covers compensation for people who had a relative or family member die of a work-related injury or disease. However, the use of the CA-7a Form is slightly different as the prime purpose of the document is to notify the nearest family of the deceased about the death. The document must be written and sent within 24 hours of the worker’s work-related death. This is not only to quicken the process of compensation but also to remove any confusions that may give rise to controversial conclusions.
Where to get Form CA-7a?
For workers or employers looking to fill out a Form CA-7a whether to request compensation or inform a family of a particular death, you can find a PDF copy of the document on the official government website of the Department of Labor. From there, you can download and print the document for you to fill out manually.
Alternatively, however, you can fill out the form digitally through PDFQuick.
How to fill out Form CA- 7a?
The CA-7a form is divided into two parts: the employee’s statement and the agency statement. The latter is more detailed than the former as all necessary details about the employee who is asking for compensation are required to validate their claim. The agency statement, on the other hand, is equally important as it will signify the truth in the information written by the employee.
Employee’s Statement
1 Name of Employee
Input the last name, given name, and then the middle initial of the employee receiving this compensation. If you are requesting compensation, this name should be yours. If you are informing a family of a particular death, input the name of the deceased here.
2 SSN
Input the Social Security Number of the Employee this document is for.
3 OWCP Number
Input the Office of Worker’s Compensation Programs (OWCP) Provider number assigned to the employee. This is so that the medical benefits can be validated properly.
4 Period Covered by This Form
5 Total Hours Claimed
Item 6
Date(s)
Input the day, month, and year of each individual day of leave.
Compensation Claimed?
If you are requesting compensation for your leave on that specific date, input “YES” and fill out the rest of the information necessary. Otherwise, input “NO” and do not fill out the other information. Inputting “NO” means that you have worked that entire day and therefore are not eligible to ask for compensation for that date.
Number of Hours
Input the number of hours spent for the following:
Type of Leave Used
If you have written some hours of leave in the previous column, input what type of leave it is.
Reason For Leave Use or Remarks
Input the reason for your leave here. If you have filed for a leave due to sickness or injury, you must submit this form alongside all medical documents that can validate that you have used your leave in that manner. It can be a medical certificate, physical therapy notes, or any other documents that are given to you by the medical center to prove that you have used your time outside of work to get medical attention.
Totals
Input the total number of hours you have inputted in each subcolumn under the Number of Hours column.
Signature of Claimant
Affix your signature here.
Date Signed
Input the day you signed this document.
7 Agency Statement or Certification
Signature of Agency Official
Submit this document to your designated agency and an official must review the validity of all information that is found in this document, most notably your hours. Once they have deemed that all the information is correct, they must affix their signature on the document.
Date Signed
Input the day the Agency Official signed this document.