Subpart A-United States Employees' Compensation Act and Extensions Thereof

SOURCE: The provisions of this Subpart A appear at 11 F.R. 177A-524, Sept. 11, 1946, redesignated at 13 F.R. 7668, Dec. 10, 1948, unless otherwise noted.

§ 01.1

Processing of claims.

(a) Claims for compensation for disability and death are processed by claims examiners in the Claims Division of the Bureau of Employees' Compensation, United States Department of Labor, whose duty is to apply the law to the facts as reported, received, or obtained upon investigation. The act requires determination of a claim, with findings of fact and an award for or against the payment of compensation, upon consideration of the claim presented by the beneficiary, and the report furnished by the immediate superior and the completion of such investigation as the Bureau may deem necessary. Hearings are not provided for by the act, nor is there any required procedure for the production of evidence. Evidence in written form is accepted. The final authority in the Bureau in the determination of a claim is vested in the Director or Acting Director of the Bureau. His final order is subject to review by the Employees' Compensation Appeals Board, United States Department of Labor, on questions of law and fact.

(b) The field employees of the Bureau are employed in accordance with procedures prescribed by the United States Civil Service Commission and the applicable forms are those prescribed by such Commission (see 5 CFR, Chapter I).

[11 F.R. 177A-524, Sept. 11, 1946, as amended at 13 F.R. 7668, Dec. 10, 1948; 25 F.R. 10793, Nov. 15, 1960]

§ 01.2 Review of decisions.

Compensation cases are subject to review by the Bureau as specified in the act. No formal application for review is required, but request for review in writing stating the ground for review is necessary to invoke action.

(Sec. 37, 39 Stat. 749, as amended; 5 U.S.C. 787)

The following forms are used under such act and extensions thereof:

CA-1 Employee's Notice of Injury and Original Claim for Compensation and Medical Treatment. (See also Forms 124.) CA-2 Official Superior's Report of Injury. (See also Forms 124.)

CA-3 Official Superior's Report of Termination of Total or Partial Disability; Report of Death.

CA-4 Employee's (or someone on his behalf) Claim for Compensation on Account of Injury. (See also Forms 124.)

CA-4A Application for Augmented Compensation for Disability.

CA-4B Application for Award for Disfigurement.

CA-5 Beneficiary's Claim for Compensation on Account of Death.

CA-5A Application for Balance of Schedule Due when Death is from Causes Other Than the Injury.

CA-8 Employee's Claim for Continuance of Compensation on Account of Disability.

CA-10 Placard for posting (containing instructions to employees on reporting injuries).

CA-11 Pamphlet containing résumé of employee's rights to compensation benefits.

CA-12 Widow or Widower's Claim for Continued Compensation on Account of Death. CA-13 Claim of Guardian of Minor Children for Continued Compensation on Account of Death.

CA-13A Dependents who are Physically Incapable of Self-support Claim for Continued Compensation on Account of Death. CA-14 Dependent Parents or Grandparents Request for Continued Compensation on Account of Death.

CA-16 Official Superior's Authorization and Request (addressed to U. 8. Hospital, U. S. Medical Officer or Designated Physician) that injured employee be provided medical treatment.

CA-17 Official Superior's Authorization and Request (addressed to U. 8. Hospital, U. 8. Medical Officer or Designated Physician) that injured employee be provided limited medical treatment where cause of injury is doubtful.

CA-20 Physician's Report of Medical Examination.

CA-32 Employee's Report of Hernia (with physician's certificate).

CA-33 Request (by Bureau) for Medical Examination.

CA-42 Affidavit Relating to Representatives of Deceased Beneficiaries (to be used where no administration of deceased employee's estate contemplated).

CA-69 Employee's Claim for Continuance of Compensation on Account of Disability when case carried on Automatic Roll.

CA-76 Physicians and Hospitals approved by Bureau which are available to injured employees.

CA-83 Employee's notice of compensation payment by Bureau.

CA-86 Official Superior's notice of compensation payment by Bureau.

CA-95 Employee's Claim for Continuance of Compensation.

CA-96 Employee's Affidavit earnings, if any, during disability.

disclosing

CS-124 Combination of Forms CA-1. CA-2 and CA-4 for use in reporting cases arising in the Far East and Southwest Pacific Areas.

ETO-124 Same, for use in reporting cases arising in the European Theater of Operations.

Std. 69 Voucher for Services and Supplies of Hospitals and Physicians.

Std. 1012 Voucher for per diem or reimbursement of expenses incidental to travel.

Std. 1034. Voucher for Purchases and Services other than personal (burial expenses); for use by undertaking establishments. US-205 Physician's Report on Permanent Eye Disabilities.

(Sec. 19, 39 Stat. 746; 5 U. S. C. 769) [14 F. R. 7373, Dec. 9, 1949]

Subpart B-Longshoremen's and Harbor Workers' Compensation Act

SOURCE: The provisions of this Subpart B appear at 11 F.R. 177A-525, Sept. 11, 1946, unless otherwise noted. Redesignated at 13 F.R. 7668, Dec. 10, 1948.

§ 01.11 Processing of claims.

(a) The deputy commissioners adjudicate claims under the Longshoremen's and Harbor Workers' Compensation Act (33 U.S.C. 919), in compensation districts established pursuant to such act. The deputy commissioner performs the quasi-judicial function of deciding the rights of private partiesthe employee, or his dependents (as the claimant or claimants), and the employer, or employer and his insurance carrier (as respondent or respondents).

(b) Claims for compensation or for reimbursement of medical expenses (where the employer has failed or neglected to furnish medical care) are processed by the deputy commissioner, with or without the assistance of claims examiners in his office, by the verification of payments, and informal adjudicatory processes, in uncontested cases. Claims not subject to informal adjustment are processed by the deputy commissioner

after pre-hearing conference (to afford amicable disposition of controversies, to narrow issues, and to simplify subsequent methods of proof), or after formal hearing provided for by the act, implemented by §§ 31.9, 31.10, 41.8, 41.9, 51.1 and 51.4 of this chapter.

(c) Formal proceedings are terminated by the filing of a compensation order containing findings of fact and award, or other order of the deputy commissioner §§ 31.12, 31.13, 31.14, 41.11, 41.12, 41.13, and 51.1 of this chapter. (Sec. 19, 44 Stat. 1435, as amended; 33 U. S. C. 919)

Review of a compensation case by the deputy commissioner may be had as prescribed by the act. The procedure outlined in the regulations requires an application to be filed in duplicate with the deputy commissioner stating the ground for review, which shall be supported by appropriate evidence (§§ 31.16, 41.15, and 51.1 of this chapter). The procedure in respect to such application for review is the same as is prescribed for claims by the act and regulations. The act does not authorize review by the Bureau of the action upon a claim by the deputy commissioner; judicial review of such action is however authorized, and the manner thereof is specified.

(Secs. 21 (b), 22, 44 Stat. 1436, 1437, as amended; 33 U. S. C. 921 (b), 922)

S 01.13 Forms.

Forms for use under the Longshoremen's Act are as follows:

US-201 Employee's first notice to Deputy Commissioner of accident or occupational disease.

US-202 Employer's first report to Deputy Commissioner of accident or occupational disease.

US-202A Employer's first report of injury (No time lost by employee).

US-203 Employee's claim for compensation.

US-204 Attending Physician's report. US-205 Physician's report on permanent eye disabilities.

US-206 Notice to the Deputy Commissioner that the payment of compensation has begun without awaiting award.

US-206-8 Notice to the Deputy Commissioner that the payment of compensation has begun without awaiting award by him.

US-207 Notice to the Deputy Commissioner that claim will be controverted.

US-208 Notice to the Deputy Commissioner that the payment of compensation has been stopped or suspended.

US-260 Notice to Deputy Commissioner of death (by dependents or on their behalf). US-261 Supplemental report of employer in death case.

US-262 Claim for compensation in death case by widow and/or children under the age of eighteen.

US-263 Claim for compensation in death cases by dependents other than widow and children of deceased (each dependent or representative must file individual claim).

US-264 Proof of death (by Physician last in attendance on Deceased).

US-265 Proof of Burial and Funeral expenses by Undertaker.

LSI-2 Application for Self-insurance.
LSI-3 Decision granting authority to Act

as Self-insurer.

LSI-4 Agreement and Undertaking of employer granted the privilege of paying compensation as self-insurer.

LSI-5c Indemnity Bond given by Selfinsurer.

LSI-8 Pay-roll report.

LSI-9 Report of compensation payments. LSI-10 Report of employer's injury experience.

LSI-11 Certificate of Authority. US-239 Certificate that employer has secured payment of compensation (by obtaining insurance policy).

US-240 Certificate that employer has secured payment of compensation (by selfinsurance).

US-241 Notice (compliance with Act by insuring with).

US-242 Notice (compliance with Act by self-insurance).

DCCA-304 Attending physician's report. DCCA-305 Physician's report on permanent eye disabilities.

DCCA-306 Notice to the Deputy Commissioner that the payment of compensation has begun without awaiting award.

DCCA-306-8 Notice to the Deputy Commissioner that the payment of compensation has begun without awaiting award by him.

DCCA-307 Notice to the Deputy Commissioner that claim will be controverted.

DCCA-308 Notice to the Deputy Commissioner that the payment, of compensation has been stopped or suspended.

DCCA-309 Request to employee that he reply to the employer's objection to his right to compensation.

DCCA-310 Employer's supplementary report of subsequent disability.

DCCA-311 Employer's supplementary report of accident or occupational disease.

DCCA-312 Notice to injured employee that case will be closed unless payments made are shown to be incorrect.

DCCA-313 Notice of election to sue (disability or death claim).

DCCA-314 Request for medical examination under District of Columbia Workmen's Compensation Act.

DCCA-315 Answer of employer or insurance carrier to employee's claim for compensation.

DCCA-315A Notice to employer and insurance carrier that answer to claim for compensation should be made.

DCCA-321 Application for lump sum award (disability or death).

DCCA-326 Subpoena.

DCCA-326A Subpoena Duces Tecum.
DCCA-326B Notice of Hearing.

DCCA-360 Notice to Deputy Commissioner of Death.

DCCA-361 Supplemental report of employer in death case.

DCCA-362 Claim for compensation in death case by widow and/or children under the age of eighteen.

DCCA-363 Claim for compensation in death cases by dependents other than widow and children of deceased (each dependent or representative must file individual claim).

DCCA-364 Proof of Death (by Physician last in attendance on deceased).

DCCA-365 Proof of Burial and Funeral expenses-by undertaker.

DCCA-402 Application for self-insurance. DCCA-403 Decision granting application of employer to pay compensation as a selfinsurer.

DCCA-404 Agreement and Undertaking of employer granted the privilege of paying compensation as self-insurer.

DCCA-405 insurer.

DCCA-411

Indemnity Bond given by self

Certificate of Authority. DCCA-439 Certificate that employer has secured payment of compensation (by obtaining insurance policy).

DCCA-440 Certificate that employer has secured payment of compensation (by selfinsurance).

DCCA-441 Notice (compliance with Act by insuring with).

DCCA-442 Notice (compliance with Act by self-insurance).

Subpart D-Defense Bases Act

SOURCE: The provisions of this Subpart D appear at 11 F.R. 177A-527, Sept. 11, 1946, unless otherwise noted. Redesignated at 13 F.R. 7668, Dec. 10, 1948. § 01.31

Processing of claims.

(See § 01.11.)

§ 01.32 Review of decisions.

(See § 01.12.) Application for judicial review is required to be instituted in the United States district court for the judicial district wherein is located the office of the deputy commissioner whose compensation order is involved, if his office is located in a judicial district, and if not so located, such judicial proceedings are required to be instituted in the judicial district nearest the place at which the injury or death occurs.

(Sec. 3, 55 Stat. 623; 42 U. S. C. 1653) § 01.33

Forms.

The same forms prescribed for use in the administration of the Longshoremen's Act are used in the administration of the act of August 16, 1941 (the so