5. Step One: Enter employee’s SSN and date of birth. This information allows the system to access the employee’s personnel data. Step Two: Indicate whether claim is for a traumatic injury (CA-1) or an occupational disease (CA-2) If information is correct, click “enter.” This will take you to the next screen. If incorrect, reenter, or click “exit.”

6. If you are completing the form on the employee’s behalf and do not have the correct SSN or birthdate, enter a placeholder figure (such as 111-22-3333). The system will then allow you to complete the form with the available information. The form, however, must be printed and then manually submitted to the ICPA.

7. PUBLIC JOHN F 05/01/1960 999-99-9999 The white fields are mandatory and must be completed by the employee. After completing each field, hit “tab” and the system will take you to the next field. Yellow fields are optional, and should only be completed if appropriate When all required fields have been completed, the system will take you to the next screen, “injury description.” Gray fields are read-only, and cannot be altered.

8. The default value for this field is 12:00 a.m on the date the form is completed. Please enter the actual date and time of the injury

9. Unless there is a specific reason for not electing COP (such as ineligibility), this block should be checked. The employee’s section of the document is now complete. Click on “print claim” to print a hard copy for the employee to sign. A copy of this should be given to the employee, with the original going to the ICPA.

10. As with the paper CA-1, the witness statement is optional. However, if a witness statement is entered, the remaining fields on this page (name, date, address) are mandatory. After entering witness data, print a copy and have the witness sign it. The signed paper copy should be forwarded to the ICPA/CPAC.

11. Make sure that this date corresponds with the date of injury given by the employee.

12. If the employee’s pay has not stopped, leave this field blank. If “no” is clicked, an explanation must be given in the box below. If “yes” is clicked, an explanation is mandatory.

13. If “yes” is entered, you must enter at least the name of the third party in item 32. If the name is unknown, give a description (e.g. “homeowner,” or “driver”)

14. If the supervisor has a substantial disagreement about the facts surrounding the claimed injury, click “no” and provide an explanation. Enter the reasons for controverting COP.

15. Once all required fields have been entered, the supervisor must print a copy of the completed CA-1. This record must then be signed by the supervisor and forwarded the ICPA for filing.

16. After clicking the “print” button, the system generates a .pdf file using the data you have entered. The information on this file should verified, and printed if correct.

17. Now that the supervisor has printed a copy, the system will allow the claim to be transmitted. To transmit the record, click “submit claim.”