Office of Workers' Compensation Programs


Federal Forms

OMB NumberTitle
1240-0061 Voluntary Demographic Survey for Office of Workers’ Compensation Programs (OWCP) Claimants
1240-0060 Division of Energy Employees Occupational Illnesses Compensation (DEEOIC) Authorization Request Forms
1240-0059 Peace Corps Volunteer Authorization for Examination and/or Treatment
1240-0058 Request for Intervention, Longshore and Harbor Workers' Compensation Act
1240-0057 Application for Self-Insurance Under the Black Lung Benefits Act
1240-0056 Medical Travel Refund Request Form
1240-0055 Authorization Request Form/Certification/Letter of Medical Necessity
1240-0054 Disclosure of Medical Evidence
1240-0053 Request for Electronic Service of Orders - Waiver of Certified Mail Requirement
1240-0052 Contractor Surveys under the Federal Employees’ Compensation Act
1240-0051 Overpayment Recovery Questionnaire
1240-0050 Pharmacy Billing Requirements
1240-0049 Representative Fee Request
1240-0048 Notice of Issuance of Insurance Policy
1240-0047 Request for Employment Information
1240-0046 Federal Employees' Compensation Act Medical Reports and Compensation Claims
1240-0045 Rehabilitation Plan and Award
1240-0044 Health Insurance Claim Form
1240-0043 Payment of Compensation Without Award
1240-0042 Notice of Controversion of Right to Compensation
1240-0041 Notice of Payments
1240-0040 Certification of Funeral Expenses under the Longshore and Harbor Workers' Compensation Act
1240-0039 Agreement and Undertaking
1240-0038 Miner's Claim for Benefits Under the Black Lung Benefits Act CM-911 and Employment History CM-911a
1240-0037 Medical Travel Refund Request
1240-0036 Longshore and Harbor Workers' Compensation Act Pre-Hearing Statement
1240-0035 Description of Coal Mine Work and Other Employment
1240-0034 Authorization for Release of Medical Information for Black Lung Benefits
1240-0033 Coal Mine Operator Response to Schedule for Submission of Additional Evidence and Operator Response to Notice of Claim
1240-0032 Request for State or Federal Workers' Compensation Information
1240-0031 Certification by School Official
1240-0030 Notice of Termination, Suspension, Reduction, or Increase in Benefit Payments
1240-0029 Request for Examination and/or Treatment
1240-0028 Report of Changes That May Affect Your Black Lung Benefits
1240-0027 Survivor's Form for Benefits Under the Black Lung Benefits Act
1240-0026 Application for Continuation of Death Benefit for Student
1240-0025 Request for Earnings Information Report
1240-0024 Certificate of Medical Necessity
1240-0023 Claim Adjudication Process for the Alleged Presence of Pneumoconiosis
1240-0022 Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death
1240-0021 Provider Enrollment Form
1240-0020 Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement
1240-0019 Uniform Billing Form
1240-0018 Claim for Reimbursement-Assisted Reemployment
1240-0017 Death Gratuity
1240-0016 Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlements
1240-0015 Claim for Continuance of Compensation (CA-12)
1240-0014 Administration of the Longshore and Harbor Workers' Compensation Act
1240-0013 Claim for Compensation by a Dependent Information Reports
1240-0012 Rehabilitation Maintenance Certificate
1240-0011 Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor
1240-0010 Request to be Selected as Payee
1240-0009 Notice of Recurrence
1240-0008 Rehabilitation Action Report
1240-0007 Claim for Medical Reimbursement Form
1240-0006 Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act
1240-0005 Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions
1240-0004 Carrier's Report of Issuance of Policy
1240-0003 Employer's First Report of Injury or Occupational Disease; Employer's Supplementary Report of Accident or Occupational Illness
1240-0002 Energy Employees Occupational Illness Compensation Program Act Forms
1240-0001 Statement of Recovery Forms

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