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November 5, 2008    DOL Home > Find It! By Form > DOL Form   

DOL Form CA-721

View ESA-OWCP-DFEC's Form 1215-0116 Online htm
Agency: ESA-OWCP-DFEC
Title: DFEC CA-721, Notice of Law Enforcement Officer's Injury Or Occupational Disease
Form Description: DFEC CA-721, Notice of Law Enforcement Officer's Injury Or Occupational Disease: This form is used by law enforcement officers to submit a claim for injury or occupational injury. It is also used by the employing organization to file a report, and by the officer's attending physician to provide a medical report.
OMB Control Number: 1215-0116
OMB Expiration Date: Tuesday, August 31, 2010




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