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E. RETURN TO WORK Yes, on what date? / / 1. Did you stop work because of your injury/illness? 2. Have you returned to work? Yes No If yes, on what date? / / 3. If you have returned to work, who are you working for now? regular duty New employer Same employer 4. What is your gross pay (before taxes) per pay period? No , skip to Section F. limited duty Self employed How often are you paid? F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS None received (.

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Form CA-16 - Authorization for Examination and/or Treatment. This form guarantees payment to the care provider if the employee requires medical treatment because of a work-related traumatic injury. Your supervisor should complete page 1 of Form CA-16 and provide it to you for your attending physicians information.

You can elect to go on Leave Without Pay and submit Form CA-7 - Claim for Compensation to request wage loss payments from the DOL. Form CA-7 alerts the DOL that you are not receiving any income and initiates wage loss pay.

DWC-7 Notice to Employees-Injuries Caused by Work (English and Spanish). This form provides your employees with information regarding workers' compensation benefits and the Medical Provider Network (MPN) in California.

CA-5. Subject. Claim for Compensation by Widow, Widower, and/or Children.

Form CA-7 is used by federal workers seeking to claim compensation for traumatic injuries suffered while on the job, as well as those who may have sustained an occupational disease during the performance of work-related duties. This form may be filled online, or downloaded and filled offline.

Federal Workers' Compensation Injured postal workers are required to fill in form CA-17, which is a form which outlines information from a doctor forbidding an injured federal employee from carrying out certain activities due to their inherently physically taxing nature.

You can upload medical documentation to the CA-7 claim in ECOMP. You must also send all medical documentation to Occupational Medical Services (OMS). The CA-7 must be filed within one year of the dates claimed, or the date your claim is accepted, whichever is later.

In case you're receiving continuation of pay, you must ask that form CA-7 be availed to you within 30 days of the COP period, and then sent over to OWCP by the 40th day of COP. Your employer will then have 5 days to submit the form to OWCP after checking it for accuracy and completion.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232