Form CA-7, Claim for Compensation Completed Form Examples and Samples
Explore a detailed example of Form CA-7, a crucial document for claiming compensation for continuation of pay after a workplace injury. This sample illustrates how to correctly fill out personal information, employment details, and injury specifics, ensuring all required fields are completed for a successful submission.
Form CA-7 Example – Continuation of Pay Claim
How this form was filled:
A sample Form CA-7 for claiming compensation for a continuation of pay after a work-related injury. Essential fields such as the claimant's personal information, injury details, and employment data are accurately filled out to demonstrate proper completion of the form.
Information used to fill out the document:
- Claimant’s Name: Jane Doe
- Employer: ABC Corporation
- Occupation: Mechanical Engineer
- Injury Description: Fracture to left arm
- Date of Injury: 02/20/2025
- Date Stopped Work: 02/20/2025
- Claimant’s Address: 456 Elm Street, Metropolis, USA
- Claimant’s Signature: Jane Doe
- Date Signed: 03/01/2025
- Supervisor’s Name: John Smith
- Supervisor’s Signature: John Smith
- Date of Signature: 03/02/2025
What this filled form sample shows:
- Thoroughly filled claimant personal information and employment details
- Accurate description of injury and relevant dates
- Includes signatures of both claimant and supervisor with dates
- Comprehensively outlines continuation of pay process
Form specifications and details:
| Use Case: | Claiming compensation for continuation of pay after a workplace injury |
| Relevant Year: | 2025 |
