Form CA-278 

Page 1 of 2 Rev. 03-2023

CLAIM FOR REIMBURSEMENT OF BENEFIT 

PAYMENTS AND CLAIMS EXPENSE UNDER 

THE WAR HAZARDS COMPENSATION ACT

U.S. Department of Labor 

Office of Workers’ Compensation Programs

Provide all information requested below. Read the instructions on the reverse of this 

form about submitting all required documentation. Failure to furnish the requested 

information will result in denial of the claim for reimbursement.

OMB Number 1240-0006 

Expiration Date: 06/30/2026 

IDENTIFYING INFORMATION

Employee's Name: OWCP File No. (if known)

Beneficiary’s Name (if fatal case)

Address (employee’s or beneficiary’s)

CLAIM

Claim is hereby made by (name and address of insurance carrier or self-insured) 

 

 

.............................................................................................................................................for reimbursement 

of benefit payments and claims expense, as authorized by 42 USC 1704(a). Claim is made only for 

amounts paid in discharge of the liability of the insurance carrier or self-insured herein arising under 

applicable workers’ compensation law, or pursuant to the terms of an applicable agreement or contract, and 

for reasonable and necessary claims expenses with respect thereto. The carrier certifies that no additional 

premium or loading was charged in this claim for a war-risk hazard as defined in 42 USC 1711(b). 

BENEFITS PAID AND AMOUNT CLAIMED AS CLAIMS EXPENSE

Periodic payments

Medical payments

Burial payments

Other

Total of Above

Claims Expenses

Period covered from

to

(inclusive dates)

AGREEMENT

The insurance carrier or self-insurer agrees: (1) to abide by the rules and regulations of the Office of 

Workers’ Compensation Programs; (2) to permit examination of the insurance records and furnish other 

information that may be requested by OWCP; (3) to reimburse OWCP to the extent the employee recovers 

damages in a third party suit; and (4) disclaims and waives any right to claim or demand, from anyone, the 

reimbursement of which is claimed herein and allowed by OWCP.

Authorized signature for insurance carrier or self-insured Date

$

$

$

$ Specify:

$

$

If you have a disability and are in need of communication assistance (such as alternate formats or sign 

language interpretation), accommodations and/or modifications, please contact OWCP. See instructions for 

additional details.
Form CA-278 

Page 2 of 2 Rev. 03-2023

Instructions for Form CA-278

1. Mail one copy of this form with the attached supporting documents described below to: 

US Department of Labor - OWCP/DFELHWC 

Attn: War Hazards 

400 West Bay Street 

Room 722 

Jacksonville, FL 32202 

 

2. File a separate form for each employee. 

 

3. Complete every item on the form. 

 

4. Attach supporting documents (i.e., receipts or copies of checks and drafts) that show the benefits paid. In 

lieu of the supporting documents, a certificate may be submitted listing benefits paid that includes (1) the 

payee, (2) the services rendered, (3) the amount paid, (4) the date paid, (5) the check or draft number, 

and (6) the signature of the certifier. 

 

5. List all expenses incurred to the date of submitting the form. Supplemental claims for reimbursement 

should be made on separate forms. 

 

6. Indicate whether the benefits paid were for detention, disability, death, etc., and state the basis for paying 

the claim (e.g., the nature of the particular war-risk hazard). 

 

7. Mark each receipt or other attachment with: 

(a) the case number appearing in the claim 

(b) the employee’s name, and 

(c) “EXHIBIT” to case to which attributable. 

 

8. Attach papers in support of each case, such as copies of any compensation award, any applicable 

contract (or sufficient excerpt), and any applicable insurance policy, marking such supporting papers as 

an “EXHIBIT” to the respective case.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of 

information unless such collection displays a valid OMB control number. Public reporting burden for this 

collection of this information is estimated to average 30 minutes per response, including time for reviewing 

instructions, searching existing data sources, gathering and maintaining the date needed, and completing 

and reviewing the collection of information. The authority for requesting this information is 42 U.S.C. 1701 et 

seq. The information will be used to determine entitlement to benefits. Furnishing the requested information 

is voluntary, but failure to provide the requested information may result in denial of the request for 

reimbursement. Send comments regarding the burden estimate or any other aspect of this collection of 

information, including suggestions for reducing this burden, to the U. S. Department of Labor, OWCP, Room 

S3229, 200 Constitution Avenue, NW, Washington, D.C., 20210, and reference OMB Control Number 

1240-0006. DO NOT SEND THE COMPLETED FORM TO THIS ADDRESS.

Request for Accommodations or Auxiliary Aids and Services

If you have a disability, federal law gives you the right to receive help from the OWCP in the form of 

communication assistance, accommodation(s) and/or modification(s) to aid you in the claims process. For 

example, we will provide you with copies of documents in alternate formats, communication services such as 

sign language interpretation, or other kinds of adjustments or changes to accommodate your disability. 

Please contact our office or your OWCP claims examiner to ask about this assistance.