Page 1 of 6

4. Name and Mailing Address of Hospital

3. Date Signed

10. Mailing Address Including ZIP Code

1. Last, First, Middle Name of Injured Officer

Notice of Law Enforcement Officer's 

Injury Or Occupational Disease

U.S. Department of Labor 

Office of Workers' Compensation Programs

Note: Persons are not required to respond to this collection of information unless it displays a currently 

valid OMB number.

OMB No. 1240-0022 

Expires: 10/31/2026 

Statement of Injured Officer

2. Date of Injury (month, day, year)

3. Hour of Injury 4. Location Where Injury Occurred (number, street, building, city, state)

5. Nature of Injury (e.g., fractured left leg) 6. Did Injury Cause Permanent Disability? 

 If Yes, Describe

7. Describe Fully Why and How Injury Occurred

I certify that the injury described above was 

sustained in performance of official duty and 

occurred in such a manner as to entitle me to 

benefits under 5 U.S.C. 8101 et seq. as 

extended by 5 U.S.C. 8191. I hereby make 

claim for compensation and medical treatment 

to which I may be entitled by reason of this 

injury.

8. Signature 9. Date Signed

Statement of Witness

1. Describe What You Saw, Heard or Know About This Injury 2. Signature

Medical Report by Physician who First Attended Injured Officer

1. Date of First Visit 

 (month, date, year)

2. Nature of Injury

3. Date of 

 Hospitalization

5. Type and Frequency of Treatment

6. In Your Opinion Was Disability A Result of the Injury Described In Item 7. Of the Statement of the Injured Officer? 

If No, State Your Reason for Believing Officer's Disability Resulted from Other Circumstances

7. Type of Further Treatment Recommended

8. Signature

10. Date Signed

9. Mailing Address Including ZIP Code

Form CA-721a 

Rev. Oct. 2022

AM PM

Yes No

Yes No

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.
Page 2 of 6

Employing Organization's Report

1. Name and Mailing Address Including ZIP Code of Employing 

Organization

2. Name of Injury Officer's Immediate Superior

3. Name and Telephone Number of Person to Contact

4. Last, First, Middle Name of Injury Officer 5. Officer's Birth Date (month, day, year) 6. Social Security Number

7. Date Employing Organization First Received Injury Notice 8. Name of Person to Whom Notice Was First Given

9. Date and Hour of Injury 10. Date and Hour Stopped Work 11. Date and Hour Pay Stopped 12. Date and Hour Returned to Work

13. Will Officer Receive Pay For 

Any Portion of Absence From 

Work Because of the Injury? 

 If yes, furnishg

A. Types(s) of Leave B. Amount Paid C. Dates For Which Leave Paid

14. Rate of Pay on Date of injury 15. List and Show Value of Other Pay Increments on Date of Injury

16. On Day of Injury 

Officer's Shift 

g

A. Began B. Ended 17. Number of Hours 

Worked Per Day 

(exclusive of overtime)

18. Circle Days Normally Worked Per Week 

(exclusive of overtime)

19. Did Officer Work for the Organization a Full 11 Months Immediately 

Prior to Injury?

20. If No, Would His Job Have Afforded Employment For 11 Months 

Except For the Injury?

21. Was Officer Performing Regular Duties When Injured? 

 If No, Give Full Explanation

22. Was the Injury Caused By:

23. If Known, Give Name and Address of Suspect(s) or Witness(es) With Whom Officer Was Involved When Injured.

24. Describe Fully How the Officer's Injury Occurred While Enforcing the Laws of the United States. If possible, give U.S. Code Citation.

25. Give Comments Regarding Completeness and Validity of the Facts Provided by Officer (attach detailed explanation if there is disagreement).

26. Signature 27. Title 28. Date Signed

Base

Subsistence, If Extra

Quarter, If Extra

$

$

$

Per

Per

Per

Per

$

$

Per

SU MO TU WE TH FR SA

AM PM

Yes No

AM PM AM PM AM PM

Yes

No

AM PM AM PM

Yes No Yes No

Yes No

Yes No

Yes No

Yes No

Form CA-721a 

Rev. Oct. 2022
Page 3 of 6

5. Has Any Pay Been Claimed or Received for the Period Shown in Item 4? 

If Yes, State Amount and List Dates

4. Period Compensation is Claimed as a Result of Pay 

Loss:

Claim for Compensation

1. Last, First, Middle Name of Injured Officer 2. Date of Injury (month, day, year)

3. Name of Employing Organization

6. Was Subsistence or Quarters Furnished During Period Shown in 

Item 4? 

If Yes, State Which and Show Value and 

inclusive Period

7. Did Officer Work For Any 

Other Employer During 

Period Shown in Item 4? 

If yes, furnishg

A. Name and Address of Employer B. Amount Earned C. Period Worked:

8. Has Claim Been Made Against Any 

Third Party For Damages on 

Account of This Injury? 

If yes, furnishg

A. Name and Address of Party B. Amount of Recovery Received

9. Was Officer Ever in the Armed 

Forces of the United States? 

If yes, furnishg

A. Service Number B. Branch of Service C. Period of Service

10. If Question 9 is Answered ''Yes'' 

Has Application Ever Been Made 

for Compensation or Pension, 

Including Retirement or Retainer 

Pay, on Account of Such Service? 

If yes, furnishg

A. Claim Number B. Name and Address of Office Where Claim is Filed C. Nature of Disability and 

Amount of Monthly 

Payment

11. Has Application Ever Been Made 

for Any Annuity on Account of 

Officer's Civilian Service With the 

United States? 

If yes, furnishg

A. Type of Annuity (e.g., civil service retirement) B. Claim Number

12. Has Application Been Made For Compensation, Annuity, or Other Benefits as a Result of This Injury Under Any 

Compensation Law, Police Disability Compensation Fund, or Other Such Fund? 

If Yes, Give Name and Address of Organization With Which Application Was Filed.

13. If Married, Give Date of 

Officer's Marriage

14. List Officer's Dependents. If None. So State

15. For Dependents Not Living With Officer, Show Amounts That He Pays for Their Support, to Whom Paid, and Payee's Address. State Whether 

Such Payments Were Ordered by A Court.

Form CA-721b 

Rev. Oct. 2022

From Through

Yes No Yes No

From

Through

Yes No

Yes No

Yes No

Yes No

Yes No

From

Through

Yes No

Name

Relationship 

To Office Date of Birth

Living with Officer? 

Yes No If Not, Show Mailing Address
Page 4 of 6

STATEMENT BY EMPLOYING ORGANIZATION: We 

hereby certify that the officer who executed the foregoing 

claim for compensation was injured while in performance of 

duty under 5 U.S.C. 8101 et seq. as extended by 5 U.S.C. 

8191. All statements made in this claim are true to the best 

of our knowledge and belief.

19. Signature

21. Title

20. Date Signed

Form CA-721b 

Rev. Oct. 2022

16. Name of Financial Institution for Depositing Benefits: Checking Savings

17. Account Number: 18. Routing or Transit Number:
Page 5 of 6

INSTRUCTIONS FOR COMPLETING THIS FORM 

(Please do not detach)

1. GENERAL. This form is used to report an injury or 

occupational disease sustained by a non-Federal law 

enforcement officer under circumstances involving a crime 

against the United States. Specifically, section 8191 of title 5, 

United States Code, provides Federal workmen's compensation 

benefits for a person determined to have been on any given 

occasion- 

(1) a law enforcement officer and to have been engaged on 

that occasion in the apprehension or attempted 

apprehension of any person- 

(A) for the commission of a crime against the United 

States, or 

(B) who at that time was sought by a law enforcement 

authority of the United States for the commission of a 

crime against the United States, or 

(C) who at that time was sought as a material witness in 

a criminal proceeding instituted by the United States: or 

(2) a law enforcement officer and to have been engaged on 

that occasion in protecting or guarding a person held for the 

commission of a crime against the United States or as a 

material witness in connection with such a crime; or 

(3) a law enforcement officer and to have been engaged on 

that occasion in the lawful prevention of, or lawful attempt to 

prevent, the commission of a crime against the United 

States; 

and to have sustained a personal injury (including disease) 

related to that occasion. Federal law enforcement officers are 

excluded from section 8191. 

If one of the above conditions is met, this form should be filed 

with the Office of Workers' Compensation Programs if the 

injured officer 

(1) is disabled and is in a, non-pay status for more than 3 

calendar days; 

(2) has permanent disability; 

(3) is unable to resume his regular work; 

(4) incurs unpaid medical expenses; or 

(5) if there is a likelihood that disability or unpaid medical 

expenses will subsequently occur. 

The form is designed so that the CLAIM FOR COMPENSATION 

page may be detached if the claim is not needed. However, read 

paragraph 6 below thoroughly before detaching the claim page. 

If additional space is needed for any answer, attach a separate 

sheet of paper and write, ''see separate sheet,'' in the 

appropriate box of this form. Please place the name of the 

injured officer (and, case file number if known) on any separate 

sheets. This form must be filed with OWCP within 5 years from 

the date of injury.

2. STATEMENT OF INJURED OFFICER. This statement must 

be completed in all instances and only by- 

(1) the injured officer, preferably 

(2) a member of his immediate family; 

(3) his guardian, personal representative, or other person 

legally authorized to act on his behalf; or 

(4) any association of law enforcement officers acting on his 

behalf. 

3. STATEMENT OF WITNESS. This statement normally is used 

if the injury was not reported at the time that it occurred or if 

some fact is not clear. It is not necessary if a report of 

investigation is submitted. 

4. MEDICAL REPORT BY PHYSICIAN WHO FIRST ATTENDED 

INJURED OFFICER. This report is not necessary if a more 

complete medical report on this form or on another form or in 

narrative is being submitted. 

5. EMPLOYING ORGANIZATION'S REPORT. This report must 

be completed in every instance. Wage information, duty hours, 

and like information should be obtained from the organization's 

records. The organization must review the injured officer's 

statement and the circumstances of the injury, and in item 25 

should comment concerning the completeness and validity of 

the officer's statement, If the organization disagrees with the 

officer's statement, it should submit a detailed explanation giving 

the reasons for its disagreement. 

6. CLAIM FOR COMPENSATION. This claim must be completed 

in every instance where the injured officer- 

(1 ) is disabled and is in a non-pay status for more than 3 

calendar days; 

(2) has permanent disability; or 

(3) is unable to resume his regular work. 

It need not be submitted where claim is made only for medical 

expenses, or if there is only a likelihood that disability or medical 

expense subsequently will occur. 

7. DIRECT DEPOSIT INFORMATION. The Department of Treasury 

requires all Federal payments be made by electronic funds transfer (EFT), 

also called Direct Deposit. You may submit a completed SF-1199A, Direct 

Deposit Sign Up, or complete the information in items 16 through 18 of 

this form. If you do not have a bank account, you may be required to 

receive your payment through Direct Express Debit MasterCard. To 

request information on the Direct Express Debit MasterCard, go to 

www.usdirectexpress.com or call 1-800-333-1795. If directed to enroll in 

the Program, you may contact for the Department of Treasury at 

1-888-224-2950 to address any questions or concerns you may have, as 

well as apply for a waiver from the process. NOTE: payments to residents 

of foreign countries are exempt from the Treasury requirement.

Form CA-721 

Rev. Oct. 2022
Page 6 of 6

The Office of Workers' Compensation Programs requires this claim before 

compensation can be awarded to an officer for pay loss, permanent 

disability, or when the Officer is unable to resume his regular work. The 

officer completes items 1 through 18 and gives it to the officer's employing 

organization which will certify as to the validity of the information 

contained in the claim by completing items 19, 20, and 21. If it does not 

agree that all answers are correct, it should attach a detailed statement 

giving the reason for its disagreement. If pay loss is involved, this claim 

should not be completed until 14 calendar days have elapsed since the 

beginning of the pay loss, or until the officer has returned to work, 

whichever occurs first.

8. ATTENDING PHYSICIAN'S MEDICAL REPORT. If the CLAIM FOR 

COMPENSATION is completed, this report is to be completed by the 

physician supervising medical treatment. It is not necessary if the CLAIM 

FOR COMPENSATION is not completed. 

9. SUBMITTING THIS FORM. This form should be turned over to the 

employing organization. The organization will have any remaining parts 

completed. Afterwards, it should review the form for completeness and to 

see that all signatures appear. If a report of investigation of any type was 

made on the injury or the incident leading to injury, a copy should be 

attached. When the form and any statements and attachments are ready 

for transmission, this instruction page should be removed. Only one copy 

of this form (the original) need be submitted.

Privacy Act

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal Employees' 

Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of Workers' 

Compensation Programs of the U. S. Department of Labor, which receives and maintains personal information on claimants and 

their immediate families. (2) Information which the Office has will be used to determine eligibility for and the amount of benefits 

payable under the FECA, and may be verified through computer matches or other appropriate means. (3) Information may be given 

to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer questions 

concerning the status of the claim, verify billing, and to consider issues relating to retention, rehire, or other relevant matters. (4) 

Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a 

decision under the FECA, to determine whether benefits are being paid properly, including whether prohibited dual payments are 

being made, and, where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by the 

FECA and/or the Debt Collection Act. (5) Failure to disclose all requested information may delay the processing of the claim or the 

payment of benefits, or may result in an unfavorable decision or reduced level of benefits. 

 

We are authorized to request a taxpayer identification number (TIN) or Social Security Number (SSN) under the Debt Collection 

Improvement Act of 1996, Title 31 U.S.C. amended section 7701(c) (1), which mandates us to require regulated entities and 

persons who are doing business with a Federal agency to furnish a TIN or SSN. The SSN or TIN, and other information maintained 

by the Office, may be used for identification, to support debt collection efforts, carried on by the Federal government and for other 

purposes required or authorized by law. 

 

 

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 60 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 5 U.S.C. 8101 et seq. The information will be used to determine entitlement to benefits. Furnishing the requested 

information is required for the claimant to obtain or retain a benefit. 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, DC 20210, and reference OMB Control Number 1240-0022. DO NOT 

SEND THE COMPLETED FORM TO THIS ADDRESS. 

 

All completed forms, documents, and inquiries should be sent to 

 

Office of Workers' Compensation Programs 

Division of Federal Employees' 

Longshore and Harbor Workers' Compensation 

Federal Employees' Compensation Act, (OWCP/DFELHWC-FECA) 

PO Box 8311 

London, KY 4072-8311 

 

 

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.

Form CA-721 

Rev. Oct. 2022