ESA/OWCP: 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/submit option:

Print Form Option

Most of DFEC’s forms are available online 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.

Form-Fill Option

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.

Electronic Fill/Submit Option

Select DFEC forms, noted with an asterisk (*) on the list of forms below, may be electronically filled and submitted to OWCP/DFEC. To do so, you must have Adobe Reader 6.x installed on your PC.

To electronically submit a DFEC form, follow these simple steps:

1. Obtain an electronic signature from Digital Signature Trust (DST). Upon opening the form, if you don't already have a digital signature on your PC, you will be directed to the DST website to obtain an electronic signature. The entire process of obtaining the electronic signature will take 5-10 business days.
   Note: Adobe 6.x is required to apply a digital signature
   
   
   (You only have to do this one time. Thereafter, you will use the same signature.)

2. Fill out the form, making sure to fill in the required fields (marked with a red asterisk (*)). If you do not fill in all the required fields, you will not be able to submit the form.
   
   It is recommended that you print the form prior to submitting, and keep the hardcopy for your records. To do so, use the [Print] button provided near the top of the form.

3. Click on the [Submit] button near the top of the form. A message will appear noting that the form has been received and will provide an identification number. It is recommended that you record the ID number on your hardcopy.

4. If you have questions about filling/submitting these forms or need other forms assistance, you can send DFEC a question via e-mail by clicking DFEC-FormsAssistance. 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.

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-17,	Duty Status Report
CA-20*,	Attending Physician's Report On-line submission now available
CA-35,	Evidence Required in Support of a Claim for Occupational Disease
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 On-line submission now available
OWCP-5b*,	Work Capacity Evaluation Cardiovascular/Pulmonary Conditions On-line submission now available
OWCP-5c*,	Work Capacity Evaluation for Musculoskeletal Conditions On-line submission now available
OWCP-16,	Rehabilitation Plan And Award
OWCP-17,	Rehabilitation Maintenance Certificate
OWCP-44*,	Rehabilitation Action Report On-line submission now available
OWCP-915,	Claim For Medical Reimbursement Form OWCP-915 replaces CA-915
OWCP-957,	Medical Travel Refund Request
HCFA-1500,	Health Insurance Claim Form
OWCP-1500,	Health Insurance Claim Form
UB-92,	Uniform Health Insurance Claim Form