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CHAPTER BUREAU OF EMPLOYEES' COMPENSATION, FEDERAL SECURITY AGENCY

Cross References: Employees' and employers' taxes under Federal Insurance Contributions

Act: See Bureau of Internal Revenue, 26 CFR Part 402. Excise tax on employers under Federal Unemployment Tax Act: See Bureau of Internal

Revenue, 26 CFR Part 403.

SUBCHAPTER A-PROCEDURES

Part 01 02

Statement of procedures.
Statement relative to substantive rules.

SUBCHAPTER B-UNITED STATES EMPLOYEES' COMPENSATION ACT

Claims for compensation and administrative procedure.
Furnishing of medical treatment.
Cases involving the liability of a third party.
Compensation for disability and death of non-citizens outside the United

States.

SUBCHAPTER C-LONGSHOREMEN'S AND HARBOR WORKERS'

COMPENSATION ACT

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SUBCHAPTER 1-DISTRICT OF COLUMBIA WORKMEN'S COMPENSATION

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General administrative provisions.
Authorization of insurance carriers.
Authorization of self-insurers.
Issuance of certificates of compliance.

SUBCHAPTER E-EXTENSION OF THE LONGSHOREMEN'S AND HARBOR

WORKERS' COMPENSATION ACT TO PERSONS ENGAGED IN EMPLOYMENT OUTSIDE CONTINENTAL UNITED STATES

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SUBCHAPTER F-COMPENSATION FOR INJURY, DISABILITY, DEATH, OR

ENEMY DETENTION OF EMPLOYEES OF CONTRACTORS WITH THE UNITED STATES

61 62

General administrative provisions.
Reimbursement of employers, insurance carriers, or compensation funds.

SUBCHAPTER A-PROCEDURES

provisions interpreted or applied are cited to text in parentheses.

SOURCE: $8 01.1 to 01.52 appear at 11 F. R. 177A-524, redesignated at 13 F. R. 7668.

Part 01—Statement of

Procedures Subpart A—United States Employees' Compensa

tion Act and Extensions Thereof Sec. 01.1 Processing of claims. 01.2 Review of decisions. 01.3 Forms. Subpart B-Longshoremen's and Harbor Work

ers' Compensation Act 01.11 Processing of claims. 01.12 Review of decisions. 01.13 Forms. Subpart C-District of Columbia Workmen's

Compensation Act 01.21 Processing of claims. 01.22 Review of decisions. 01.23 Forms.

Subpart D-Defense Bases Act 01.31 Processing of claims. 01.32 Review of decisions. 01.33 Forms. Subpart E-Disability, Death and Detention

Benefits; Employees of Contractors 01.41 General procedures. 01.42 Forms.

Subpart F-Reimbursable Insurance Claims 01.51 General procedures. 01.52 Form.

AUTHORITY: $801.1 to 01.52 issued under sec. 32, 39 Stat. 749; 5 U. S. C. 783. Statutory

SUBPART A-UNITED STATES EMPLOYEES' COM. PENSATION ACT AND EXTENSIONS THEREOF

$ 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 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, Office of Special Services, Federal Security Agency, 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).

$ 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)

8 01.3 Forms. 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 Termi. nation 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-5 Beneficiary's Claim for Compensation on Account of Death.

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 Chil. dren 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. S. 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. S. Hospital, U. S. 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 43 Affidavit of Undertaker re Burial Expenses.

CA-53 Employee's Instructions for submitting Vouchers for Travel Expenses (to accompany Standard Form 1012).

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 disclosing earnings, if any, during disability.

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) SUBPART ALONGSHOREMEN'S AND HARBOR

WORKERS' COMPENSATION ACT $ 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 parties—the 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 S$ 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)

8 01.12 Review of decisions. 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 (88 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)

§ 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-209 Request to employee that he reply to the employer's objection to his right to compensation.

US-210 Employer's supplementary report of subsequent disability.

US-211 Employer's supplementary report of accident or occupational disease.

U8-212 Notice to injured employee that case will be closed unless reports now on file are shown to be incorrect.

U8–213 Notice of election to sue (disabllity or death claim).

US-214 Request for medical examination under United States Longshoremen's and Harbor Workers' Compensation Act,

US-215 Answer of employer or insurance carrier to employee's claim for compensation.

US-215A Notice to employer and insurance carrier that answer to claim for compensation should be made.

US-216 Request for additional reports. US-221 Application for lump sum award (disability or death).

US-224 Application to determine reason. ableness of physician's bill or medical charges under section 7.

US-226 Subpoena.
US-226A Subpoena Duces Tecum.
US-226B Notice of Hearing.

U8–227 Attending Physician's supplementary report.

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).

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