Form CA-278 Claim for Reimbursement of Benefit Payments and Claims E

CLAIM FOR REIMBURSEMENT OF BENEFIT
PAYMENTS AND CLAIMS EXPENSE UNDER
THE WAR HAZARDS COMPENSATION ACT

U.S. Department of Labor
Employment Standards Administration
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 1215-0202
Expiration Date: 06/30/2007

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. This claim does not contain, nor will
the insurance carrier or self-insured demand, a claim for an additional charge or loading for war-risk
hazard, as defined in 42 USC 1711(b).
BENEFITS PAID AND AMOUNT CLAIMED AS CLAIMS EXPENSE
Periodic payments

$________________

Claims Expense $_______________

Medical payments

$________________

Period covered from _______________

Burial Payments

$________________

Other (specify)

$________________

to _______________
(inclusive dates)

Total of above

$________________

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

Form CA-278
January 2004

Instructions for Form CA-278
1. Mail one copy of this form with the attached supporting documents described below to the U.S.
Department of Labor, Office of Workers’ Compensation Programs, 1240 East 9th Street, Room 851,
Cleveland, Ohio 44199, unless otherwise instructed.
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
Under the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 1215-0202. We estimate that it will take an average
of thirty minutes to complete this collection of information, including time for reviewing instructions,
gathering information from the respondent’s records and entering the data onto the form. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to the Office of Workers’ Compensation Programs, U.S. Department of Labor,
Room S-3229, 200 Constitution Avenue NW, Washington, DC 20210; and to the Office of Management and
Budget, Paperwork Reduction Project (1215-0202), Washington, DC 20503. DO NOT SEND THE
COMPLETED FORM TO EITHER OF THESE OFFICES.

Form CA-278
January 2004