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Division of Federal Employees' Compensation (DFEC)

Forms

OWCP's Division of Federal Employees' Compensation has made a variety of forms available online. These forms are only available in PDF format. In order to view and/or print PDF documents you must have a PDF viewer. It is highly recommended that you have the most current version (click on Adobe Acrobat Reader to download the current version) available on your workstation.

The forms in the list below may be completed manually via the print form option or electronically via the electronic fill option:

Printable Forms

All of DFEC's online forms (with the exception of Forms CA-16, CA-26 and CA-27) are available to print and to manually fill and submit. Simply click on the appropriate form and print it using the [Print] button provided near the top of the form. Write or type the required information on the hardcopy and authorize the form, if applicable, with a hand-written signature. Then mail or fax the completed form to the DFEC office you normally send to for this process.

Fillable Forms

Forms noted with an asterisk (*) may be electronically filled. Simply click on the appropriate form, fill out the form using your computer keyboard and the <TAB> key or your mouse to navigate between form fields. Print the form (use the Print button on or near the top of the form), authorize the form (if applicable provide hand-written signature) and mail or fax the completed form to the DFEC office you normally send to for this process.

If you have questions about filling these forms or need other forms assistance, you can send DFEC a question via e-mail by clicking DFEC-FormsAssist. DFEC will respond to your question via e-mail.

NOTE: When printing these files please remember to use the Adobe Acrobat Reader print icon or the [Print] button on the form, itself, and NOT your browser's print icon on the browser toolbar.

Questions? Please visit DFEC’s Frequently Asked Questions page.

Form Number

OWCP's Form Title / Description

CA-1*

Federal Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation

CA-2*

Notice of Occupational Disease and Claim for Compensation

CA-2a*

Notice of Recurrence

CA-5*

Claim for Compensation by Widow, Widower, and/or Children

CA-5b*

Claim for Compensation by Parents, Brothers, Sisiters, GrandParents, or GrandChildren

CA-6

Official Supervisor's Report of Employee's Death

CA-7*

Claim for Compensation

Form CA-7 replaces ALL prior versions of CA-7 & CA-8 (see FECA Bulletin No. 99-18)

CA-7a*

Time Analysis Form, used for claiming compensation, including repurchase of paid leave

CA-7b

Leave Buy Back (LBB) Worksheet/Certification and Election

CA-10

What A Federal Employee Should Do When Injured At Work

CA-12*

Claim For Continuance of Compensation Under the Federal Employees' Compensation Act

CA-16

Authorization for Examination and/or Treatment

This form is only available to authorized employing agency personnel, and may be obtained in electronic format via the Agency Query System (AQS) or ECOMP, or by contacting the employing agency workers’ compensation personnel.

CA-17*

Duty Status Report

CA-20*

Attending Physician's Report

CA-26

Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs

This form is only available to registered medical providers by logging into the OWCP Web Bill Portal. To submit the form, providers must click on the 'Provider' Link to the right of the FECA oval located at the top left of the home page, login with their user ID and password, and then click on the 'LMN Documents' link located in the left menu bar. For providers not yet registered, after clicking the 'Provider' link, click the 'Web Registration' link located in the left menu bar to register for web access. For providers not yet enrolled, click on 'Forms & Links' in the horizontal menu at the top of the home page to download the Provider Enrollment form and instructions.

CA-27

Authorization Request Form and Certification/Letter of Medical Necessity for Opioid Medications

This form is only available to registered medical providers by logging into the OWCP Web Bill Portal. To submit the form, providers must click on the 'Provider' Link to the right of the FECA oval located at the top left of the home page, login with their user ID and password, and then click on the 'LMN Documents' link located in the left menu bar. For providers not yet registered, after clicking the 'Provider' link, click the 'Web Registration' link located in the left menu bar to register for web access. For providers not yet enrolled, click on 'Forms & Links' in the horizontal menu at the top of the home page to download the Provider Enrollment form and instructions.

CA-35

Evidence Required in Support of a Claim for Occupational Disease

CA-40*

Designation of a Recipient of the Federal Employees' Compensation Act Death Gratuity Payment under 5 U.S.C. § 8102a

CA-41*

Claim for Survivor Benefits Under the Federal Employees’ Compensation Act Section 8102a Death Gratuity

CA-42*

Official Notice of Employees’ Death for Purposes of FECA Section 8102a Death Gratuity

CA-278

Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act

CA-721*

Notice of Law Enforcement Officer's Injury Or Occupational Disease

CA-722*

Notice of Law Enforcement Officer's Death

CA-1031

Letter to Dependants to Verify Claimant Support

CA-1074

Letter to Parents in Death Claim Development

CA-1108*

Statement of Recovery Letter with Long Form

CA-1122*

Statement of Recovery Letter with Short Form

CA-2231*

Claim for Reimbursement Assisted Reemployment

OWCP-5a*

Work Capacity Evaluation Psychiatric/Psychological Conditions

OWCP-5b*

Work Capacity Evaluation Cardiovascular/Pulmonary Conditions

OWCP-5c*

Work Capacity Evaluation for Musculoskeletal Conditions

OWCP-16*

Rehabilitation Plan And Award

OWCP-17*

Rehabilitation Maintenance Certificate

OWCP-20*

Overpayment Recovery Questionnaire

OWCP-44*

Rehabilitation Action Report

OWCP-04

Uniform Billing Form

OWCP-915*

Claim For Medical Reimbursement

Form OWCP-915 replaces CA-915

OWCP-957*

Medical Travel Refund Request

OWCP-1168

Provider Enrollment form

OWCP-1500*

Health Insurance Claim Form

SF1199A

Direct Deposit Sign-Up Form