Office of Workers' Compensation Programs

OWCP

Federal Forms

Forms

OMB Number	Title
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 Forms/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