Form CA-7, Claim for Compensation Instructions

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This form contains 203 fields organized into 22 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Additional Information
CA-7[0].Page1[0].Section4[0].radYN0_p1_s4[0]_0 ComboBox
Select 'Yes' or 'No' for the question in Section 4.
CA-7[0].Page1[0].Section4[0].radYN0_p1_s4[0]_1 ComboBox
Select 'Yes' or 'No' for the question in Section 4.
CA-7[0].Page1[0].Section4[0].radYN0_p1_s4_1[0]_0 ComboBox
Select 'Yes' or 'No' for the question in Section 4.
CA-7[0].Page1[0].Section4[0].radYN0_p1_s4_1[0]_1 ComboBox
Select 'Yes' or 'No' for the question in Section 4.
CA-7[0].Page2[0].Section9[0].radYN0_p2_s8_b[0]_0 ComboBox
Select this option if the answer to the corresponding question is 'Yes'.
CA-7[0].Page2[0].Section9[0].radYN0_p2_s8_b[0]_1 ComboBox
Select this option if the answer to the corresponding question is 'No'.
CA-7[0].Page2[0].Section9[0].radYN0_p2_s8_c[0]_0 ComboBox
Select this option if the answer to the corresponding question is 'Yes'.
CA-7[0].Page2[0].Section9[0].radYN0_p2_s8_c[0]_1 ComboBox
Select this option if the answer to the corresponding question is 'No'.
Remarks Text
Provide any additional remarks or information relevant to the compensation claim.
Agency Information
Title Text
Enter the title of the person completing this section of the form.
Name of Agency Text
Enter the name of the employing agency.
Name Text
Enter the name of the person completing this section of the form.
Title Text
Enter the title of the person completing this section of the form.
E-Mail Address Text
Enter the email address of the person completing this section of the form. Maximum length is 20 characters.
Max length: 20 characters
Telephone No Text
Enter the telephone number of the person completing this section of the form.
Fax No Text
Enter the fax number of the person completing this section of the form.
Claim Details
Enter type of wage loss Text
Specify the type of wage loss you are claiming. This could include total disability, partial disability, or other types of wage loss.
CA-7[0].Page1[0].Section2[0].radYN0_p1_s2_ia[0]_0 ComboBox
Select 'Yes' or 'No' to indicate if you have any other claims related to this injury.
CA-7[0].Page1[0].Section2[0].radYN0_p1_s2_ia[0]_1 ComboBox
Select 'Yes' or 'No' to indicate if you have any other claims related to this injury.
CA-7[0].Page1[0].Section2[0].radYN0_p1_s2_ib[0]_0 ComboBox
Select 'Yes' or 'No' to indicate if you have received any other compensation for this injury.
CA-7[0].Page1[0].Section2[0].radYN0_p1_s2_ib[0]_1 ComboBox
Select 'Yes' or 'No' to indicate if you have received any other compensation for this injury.
Full Address of VA Office Where Claim Filed Text
Provide the full address of the Veterans Affairs office where you filed your claim.
Max length: 30 characters
68c8 Text
Enter the city of the Veterans Affairs office where you filed your claim.
Max length: 30 characters
Choose State ComboBox
Select the state of the Veterans Affairs office where you filed your claim from the dropdown list.
AR FL ID MP PA SC GU AL NH NJ WV MS VI WY CO OH WA SD WI CA ME PR OR IN MN AK TN HI MT KY PW AZ KS RI NM LA VT IL ND VA NE AS NC DE OK CT IA MA TX DC GA MO NV MI NY UT MH MD FM
Zip code Text
Enter the ZIP code of the Veterans Affairs office where you filed your claim.
Max length: 5 characters
Code Text
Enter the code relevant to your claim. This could be a specific code provided by your employer or the Department of Labor.
Max length: 20 characters
Choose plan ComboBox
Choose the retirement plan you are enrolled in from the options provided.
FERS CSRS Other
Claim Information
c. OWCP File Number Text
Enter your OWCP (Office of Workers' Compensation Programs) file number. This field allows up to 9 characters.
Max length: 9 characters
Compensation Details
Date Annuity Began Text
Enter the date when your annuity began. Use the format MM/DD/YYYY.
Amount of Monthly Payment Text
Enter the amount of your monthly payment. This should be the total monthly compensation you receive.
Type Text
Enter the type of compensation or benefit you are claiming.
Show Pay Rate as of Text
Enter the date as of which the pay rate is being shown. Use the format MM/DD/YYYY.
per Text
Specify the period for which the pay rate is applicable (e.g., per hour, per day, per week).
5d6b $ 6aab per Text
Enter the amount of compensation in dollars and specify the time period (e.g., per hour, per day).
Type Text
Specify the type of compensation being claimed.
b884 Text
Enter the specific type of compensation or benefit code.
b884 $ 5458 per Text
Enter the amount of compensation in dollars and specify the time period (e.g., per hour, per day).
Enter pay Text
Enter the pay rate for the employee.
per Text
Specify the time period for the pay rate (e.g., per hour, per day).
Date Text
Enter the date relevant to the compensation claim (e.g., date of injury, date of claim).
CA-7[0].Page2[0].Section12[0].radYN0_p2_s12_ib[0]_0 ComboBox
Select 'Yes' or 'No' to indicate if you have received any other compensation for this injury.
CA-7[0].Page2[0].Section12[0].radYN0_p2_s12_ib[0]_1 ComboBox
Select 'Yes' or 'No' to indicate if you have received any other compensation for this injury.
CA-7[0].Page2[0].Section12[0].radYN0_p2_s12_ic[0]_0 ComboBox
Select 'Yes' or 'No' to indicate if you have received any other benefits for this injury.
CA-7[0].Page2[0].Section12[0].radYN0_p2_s12_ic[0]_1 ComboBox
Select 'Yes' or 'No' to indicate if you have received any other benefits for this injury.
CA-7[0].Page2[0].Section12[0].radYN0_p2_s12_id[0]_0 ComboBox
Select 'Yes' or 'No' to indicate if you have received any other payments for this injury.
CA-7[0].Page2[0].Section12[0].radYN0_p2_s12_id[0]_1 ComboBox
Select 'Yes' or 'No' to indicate if you have received any other payments for this injury.
Explain Text
Provide an explanation if you answered 'Yes' to any of the previous questions regarding other compensation, benefits, or payments.
If Yes, date Text
If you answered 'Yes' to any of the previous questions, provide the date when you received the other compensation, benefits, or payments.
Compensation Period
From Text
Enter the start date for the period of compensation being claimed in Section 11 on Page 2.
Dependent Information
CA-7[0].Page1[0].Section2[0].radYN0_p1_s2_ic[0]_0 ComboBox
Select 'Yes' or 'No' to indicate if you have any dependents that should be considered in this claim.
CA-7[0].Page1[0].Section2[0].radYN0_p1_s2_ic[0]_1 ComboBox
Select 'Yes' or 'No' to indicate if you have any dependents that should be considered in this claim.
Name Text
Enter the name of your dependent.
Max length: 30 characters
Social Security Text
Enter the Social Security Number of your dependent.
Date of Birth Text
Enter the date of birth of your dependent in the format MM/DD/YYYY.
Relationship Text
Enter the relationship of the dependent to the employee (e.g., spouse, child).
Max length: 30 characters
CA-7[0].Page1[0].Section5[0].radYN0_p1_s5_lou1[0]_0 ComboBox
Select 'Yes' if the dependent is living with the employee, otherwise select 'No'.
CA-7[0].Page1[0].Section5[0].radYN0_p1_s5_lou1[0]_1 ComboBox
Select 'No' if the dependent is not living with the employee, otherwise select 'Yes'.
7ce1 Text
Enter the name of the dependent.
Max length: 30 characters
a7f9 Text
Enter the date of birth of the dependent.
6e0e Text
Enter the relationship of the second dependent to the employee (e.g., spouse, child).
Max length: 30 characters
CA-7[0].Page1[0].Section5[0].radYN0_p1_s5_lou2[0]_0 ComboBox
Select 'Yes' if the second dependent is living with the employee, otherwise select 'No'.
CA-7[0].Page1[0].Section5[0].radYN0_p1_s5_lou2[0]_1 ComboBox
Select 'No' if the second dependent is not living with the employee, otherwise select 'Yes'.
a. Are you making support payments for a dependent noted above or on your attachment(s) Text
Indicate whether you are making support payments for a dependent listed in the form or any attachments.
Max length: 30 characters
a642 Text
Provide additional information regarding the support payments for a dependent.
City Text
Enter the city where the dependent resides.
State ComboBox
Select the state where the dependent resides from the provided list.
AR FL ID MP PA SC GU AL NH NJ WV MS VI WY CO OH WA SD WI CA ME PR OR IN MN AK TN HI MT KY PW AZ KS RI NM LA VT IL ND VA NE AS NC DE OK CT IA MA TX DC GA MO NV MI NY UT MH MD FM
ZIP Code Text
Enter the ZIP code where the dependent resides. The ZIP code should be 5 digits long.
Max length: 5 characters
CA-7[0].Page1[0].Section5[0].radYN0_p1_s5_b[0]_0 ComboBox
Select 'Yes' if you are making support payments for a dependent noted above or on your attachments.
CA-7[0].Page1[0].Section5[0].radYN0_p1_s5_b[0]_1 ComboBox
Select 'No' if you are not making support payments for a dependent noted above or on your attachments.
Disability Information
Nature of Disability and Monthly Payment Text
Describe the nature of your disability and the monthly payment you receive for it.
Max length: 20 characters
4ca8 Text
Provide additional details about the nature of your disability and the monthly payment, if applicable.
Earnings from Outside Employment
CA-7[0].Page1[0].Section3[0].radYN0_p1_s3[0]_0 ComboBox
Select 'Yes' or 'No' to indicate if you have any outside employment earnings.
CA-7[0].Page1[0].Section3[0].radYN0_p1_s3[0]_1 ComboBox
Select 'Yes' or 'No' to indicate if you have any outside employment earnings.
Employee Information
Name and Address of Business Text
Enter the name and address of the business where you are employed.
Address Text
Enter the full address of the business where you are employed.
City Text
Enter the city of the business address.
State ComboBox
Select the state of the business address from the dropdown list.
AR FL ID MP PA SC GU AL NH NJ WV MS VI WY CO OH WA SD WI CA ME PR OR IN MN AK TN HI MT KY PW AZ KS RI NM LA VT IL ND VA NE AS NC DE OK CT IA MA TX DC GA MO NV MI NY UT MH MD FM
ZIP Code Text
Enter the ZIP code of the business address. Maximum length is 5 characters.
Max length: 5 characters
Address line 1 Text
Enter the first line of the business address.
Address line 2 Text
Enter the second line of the business address, if applicable.
2a60 Text
Enter the city of the business address.
3071 ComboBox
Select the state of the business address from the dropdown list.
AR FL ID MP PA SC GU AL NH NJ WV MS VI WY CO OH WA SD WI CA ME PR OR IN MN AK TN HI MT KY PW AZ KS RI NM LA VT IL ND VA NE AS NC DE OK CT IA MA TX DC GA MO NV MI NY UT MH MD FM
Grade Text
Enter the grade level of the employee at the time of injury.
step Text
Enter the step level of the employee at the time of injury.
Grade Text
Enter the grade level of the employee.
step Text
Enter the step level of the employee.
Employee Pay Information
Enter pay Text
Enter the employee's pay rate at the time of injury.
per Text
Specify the pay period (e.g., per hour, per day, per week) for the entered pay rate.
Type Text
Specify the type of pay (e.g., base pay, overtime).
Enter pay Text
Enter any additional pay the employee received.
7ec9 $ Obc4 per Text
Specify the pay period for the additional pay entered.
Type Text
Specify the type of additional pay (e.g., bonus, hazard pay).
2679 Text
Enter the amount of the specified additional pay.
2679 $ 5f6d per Text
Specify the pay period for the additional pay amount entered.
Additional Pay Text
Specify any other type of additional pay not previously listed.
Additional Pay 4ad3 Text
Enter the amount for the other type of additional pay specified.
Additional Pay 4ad3 $ ecd7 per Text
Specify the pay period for the other type of additional pay amount entered.
Type Text
Specify another type of additional pay if applicable.
5d6b Text
Enter the amount for the other type of additional pay specified.
Employment Details
Dates Worked Text
Enter the dates you worked, in the format MM/DD/YYYY.
Date (MM/DD/YYYY) Text
Enter the date in the format MM/DD/YYYY.
Date (MM/DD/YYYY) Text
Enter the date in the format MM/DD/YYYY.
Date (MM/DD/YYYY) Text
Enter the date in the format MM/DD/YYYY.
Type of Work Text
Specify the type of work you performed.
CA-7[0].Page2[0].Section13[0].radYN0_p2_s13_a[0]_0 ComboBox
Select 'Yes' or 'No' to indicate if you have worked for any other employer during the period of claimed compensation.
CA-7[0].Page2[0].Section13[0].radYN0_p2_s13_a[0]_1 ComboBox
Select 'Yes' or 'No' to indicate if you have worked for any other employer during the period of claimed compensation.
Form Actions
Print form Button
Click this button to print the form.
Reset form Button
Click this button to reset the form to its default state.
Form Information
TextField1 Text
This field is for the form version identifier. It is pre-filled with 'CA-7 (Rev. 09-14)'.
133f Text
This field is pre-filled with the form version information and does not require user input.
Form Metadata
TextField1 Text
This field is pre-filled with the form version information for Page 3.
TextField1 Text
This field is pre-filled with the form version information for Page 4.
General Information
Το Text
Please provide the required information for this field.
Το Text
Please provide the required information for this field.
Το Text
Please provide the required information for this field.
Το Text
Please provide the required information for this field.
Date (MM/DD/YYYY) Text
Enter the date in MM/DD/YYYY format.
Το Text
Please provide the required information for this field.
Injury Details
d. Date of Injury Month Day Year Text
Enter the date when the injury occurred. Use the format Month/Day/Year.
CA-7[0].Page1[0].Section2[0].radYN0_p1_s2[0]_0 ComboBox
Select 'Yes' or 'No' for the corresponding question in Section 2.
CA-7[0].Page1[0].Section2[0].radYN0_p1_s2[0]_1 ComboBox
Select 'Yes' or 'No' for the corresponding question in Section 2.
CA-7[0].Page1[0].Section2[0].radYN0_p1_s2[0]_2 ComboBox
Select 'Yes' or 'No' for the corresponding question in Section 2.
CA-7[0].Page1[0].Section2[0].radYN0_p1_s2[0]_3 ComboBox
Select 'Yes' or 'No' for the corresponding question in Section 2.
Date (MM/DD/YYYY) Text
Enter the date in MM/DD/YYYY format.
Date (MM/DD/YYYY) Text
Enter the date in MM/DD/YYYY format.
Date (MM/DD/YYYY) Text
Enter the date in MM/DD/YYYY format.
Date (MM/DD/YYYY) Text
Enter the date in MM/DD/YYYY format.
Date (MM/DD/YYYY) Text
Enter the date in MM/DD/YYYY format.
CA-7[0].Page1[0].Section5[0].radYN0_p1_s2_ia[0]_0 ComboBox
Select 'Yes' if the injury occurred while performing duties for the United States, otherwise select 'No'.
CA-7[0].Page1[0].Section5[0].radYN0_p1_s2_ia[0]_1 ComboBox
Select 'No' if the injury did not occur while performing duties for the United States, otherwise select 'Yes'.
CA-7[0].Page1[0].Section6[0].radYN0_p1_s6_c[0]_1 ComboBox
Indicate whether the answer to the question in Section 6 is 'Yes' or 'No'.
CA-7[0].Page1[0].Section6[0].radYN0_p1_s2[0]_0 ComboBox
Indicate whether the answer to the question in Section 2 is 'Yes' or 'No'.
CA-7[0].Page1[0].Section6[0].radYN0_p1_s2[0]_1 ComboBox
Indicate whether the answer to the question in Section 2 is 'Yes' or 'No'.
CA-7[0].Page1[0].Section6[0].radYN0_p1_s2[0]_2 ComboBox
Indicate whether the answer to the question in Section 2 is 'Yes' or 'No'.
CA-7[0].Page1[0].Section6[0].radYN0_p1_s2[0]_3 ComboBox
Indicate whether the answer to the question in Section 2 is 'Yes' or 'No'.
Date Text
Enter the date of injury or the date the condition began.
CA-7[0].Page2[0].Section10[0].radYN0_p2_s10_a[0]_0 ComboBox
Indicate 'Yes' or 'No' for the first question in Section 10 on Page 2.
CA-7[0].Page2[0].Section10[0].radYN0_p2_s10_a[0]_1 ComboBox
Indicate 'Yes' or 'No' for the first question in Section 10 on Page 2.
CA-7[0].Page2[0].Section10[0].radYN0_p2_s10_b[0]_0 ComboBox
Indicate 'Yes' or 'No' for the second question in Section 10 on Page 2.
CA-7[0].Page2[0].Section10[0].radYN0_p2_s10_b[0]_1 ComboBox
Indicate 'Yes' or 'No' for the second question in Section 10 on Page 2.
Class Text
Enter the class or category of the injury or condition in Section 10 on Page 2. Maximum length is 20 characters.
Max length: 20 characters
CA-7[0].Page2[0].Section10[0].radYN0_p2_s10_c[0]_0 ComboBox
Indicate 'Yes' or 'No' for the third question in Section 10 on Page 2.
CA-7[0].Page2[0].Section10[0].radYN0_p2_s10_c[0]_1 ComboBox
Indicate 'Yes' or 'No' for the third question in Section 10 on Page 2.
CA-7[0].Page2[0].Section10[0].radYN0_p2_s10_d[0]_0 ComboBox
Indicate 'Yes' or 'No' for the fourth question in Section 10 on Page 2.
CA-7[0].Page2[0].Section10[0].radYN0_p2_s10_d[0]_1 ComboBox
Indicate 'Yes' or 'No' for the fourth question in Section 10 on Page 2.
CA-7[0].Page2[0].Section11[0].radYN0_p2__s11_i[0]_0 ComboBox
Select 'Yes' or 'No' for the corresponding question in Section 11.
CA-7[0].Page2[0].Section11[0].radYN0_p2__s11_i[0]_1 ComboBox
Select 'Yes' or 'No' for the corresponding question in Section 11.
Leave Information
Sick Leave From Text
Enter the start date of your sick leave in MM/DD/YYYY format.
Annual Leave From Text
Enter the start date of your annual leave in MM/DD/YYYY format.
Leave without Pay From Text
Enter the start date of your leave without pay in MM/DD/YYYY format.
CA-7[0].Page2[0].Section12[0].radYN0_p2_s12_ia[0]_0 ComboBox
Select 'Yes' or 'No' for the corresponding question in Section 12.
CA-7[0].Page2[0].Section12[0].radYN0_p2_s12_ia[0]_1 ComboBox
Select 'Yes' or 'No' for the corresponding question in Section 12.
Other Claims
CA-7[0].Page1[0].Section6[0].radYN0_p1_s6_a[0]_0 ComboBox
Select 'Yes' if you have any other claims related to compensation.
CA-7[0].Page1[0].Section6[0].radYN0_p1_s6_a[0]_1 ComboBox
Select 'No' if you do not have any other claims related to compensation.
CA-7[0].Page1[0].Section6[0].radYN0_p1_s6[0]_0 ComboBox
Select 'Yes' if you have any other claims related to compensation. Otherwise, select 'No'.
CA-7[0].Page1[0].Section6[0].radYN0_p1_s6[0]_1 ComboBox
Select 'No' if you do not have any other claims related to compensation. Otherwise, select 'Yes'.
CA-7[0].Page1[0].Section6[0].radYN0_p1_s6_c[0]_0 ComboBox
Select 'Yes' if you have any other claims related to compensation. Otherwise, select 'No'.
CA-7[0].Page2[0].Section13[0].radYN0_p2_s13_b[0]_0 ComboBox
Indicate whether the employee has any other relevant claims related to compensation.
CA-7[0].Page2[0].Section13[0].radYN0_p2_s13_b[0]_1 ComboBox
Indicate whether the employee has any other relevant claims related to compensation.
Personal Information
Last Text
Enter your last name.
First Text
Enter your first name.
Middle Text
Enter your middle initial. This field allows only one character.
Max length: 1 characters
b. Mailing Address (Including City State, ZIP Code) Text
Enter your mailing address, including city, state, and ZIP code.
aa92 Text
Enter the second line of your mailing address, if applicable.
aa92 d1a5 Text
Enter the city of your mailing address.
aa92 d1a5 983a ComboBox
Select the state of your mailing address from the dropdown list.
AR FL ID MP PA SC GU AL NH NJ WV MS VI WY CO OH WA SD WI CA ME PR OR IN MN AK TN HI MT KY PW AZ KS RI NM LA VT IL ND VA NE AS NC DE OK CT IA MA TX DC GA MO NV MI NY UT MH MD FM
aa92 d1a5 983a 88bf Text
Enter the ZIP code of your mailing address. This field allows up to 5 characters.
Max length: 5 characters
E-Mail Address (Optional) Text
Enter your email address. This field is optional.
e. Social Security Number Text
Enter your Social Security Number.
f. Telephone No./FAX No Text
Enter your telephone number and/or fax number.
180b Text
Enter your fax number.
Date (MM/DD/YYYY) Text
Enter the date in MM/DD/YYYY format. This is likely the date of the injury or the date you are filling out the form.
3058 Text
Enter the ZIP code of your address.
Max length: 5 characters
Social security number Text
Enter the employee's Social Security Number.
Claim Number Text
Enter the claim number assigned to your case. This is usually provided by the Department of Labor.
Max length: 20 characters
Claim Number Text
Enter the claim number associated with your compensation claim. This number is provided by the Department of Labor.
Max length: 20 characters
Work Hours
Enter hours Text
Enter the number of hours worked on Sunday.
Enter hours Text
Enter the number of hours worked on Monday.
Enter hours Text
Enter the number of hours worked on Tuesday.
Enter hours Text
Enter the number of hours worked on Wednesday.
Enter hours Text
Enter the number of hours worked on Thursday.
Enter hours Text
Enter the number of hours worked on Friday.
Enter hours Text
Enter the number of hours worked on Saturday.
Enter hours Text
Enter the number of hours worked on Sunday.
Enter hours Text
Enter the number of hours worked on Monday.
Enter hours Text
Enter the number of hours worked on Tuesday.
Enter hours Text
Enter the number of hours worked on Wednesday.
Enter hours Text
Enter the number of hours worked on Thursday.
Enter hours Text
Enter the number of hours worked on Friday.
Enter hours Text
Enter the number of hours worked on Saturday.
CA-7[0].Page2[0].Section9[0].radYN0_p2_s9_1[0]_0 ComboBox
Select 'Yes' if you worked on Sunday.
CA-7[0].Page2[0].Section9[0].radYN0_p2_s9_1[0]_1 ComboBox
Select 'No' if you did not work on Sunday.
Check to select CheckBox
Check this box if you worked on Sunday.
Check to select CheckBox
Check this box if you worked on Monday.
Check to select CheckBox
Check this box if you worked on Tuesday.
Check to select CheckBox
Check this box if you worked on Wednesday.
Check to select CheckBox
Check this box if you worked on Thursday.
Work Schedule
Check to select CheckBox
Check this box if you are selecting Friday as a day relevant to your claim.
Check to select CheckBox
Check this box if you are selecting Saturday as a day relevant to your claim.
From Text
Enter the start date for the first week relevant to your claim.
To Text
Enter the end date for the first week relevant to your claim.
From Text
Enter the start date for the second week relevant to your claim.
To Text
Enter the end date for the second week relevant to your claim.