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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. Mar 2017