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This version of the form is not currently in use and is provided for reference only. Download this version of
Form CA-1122
for the current year.
Form CA-1122 Short Form Statement of Recovery
What Is Form CA-1122?
This is a legal form that was released by the U.S. Department of Labor on May 1, 2015 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form CA-1122?
A: Form CA-1122 is the Short Form Statement of Recovery.
Q: What is the purpose of Form CA-1122?
A: The purpose of Form CA-1122 is to provide a summary of the amount of recovery sought for any workers' compensation claim.
Q: Who needs to complete Form CA-1122?
A: Employers or their insurance carriers need to complete Form CA-1122.
Q: When should Form CA-1122 be completed?
A: Form CA-1122 should be completed at the time a claim is filed or within 20 days of the initial indemnity payment.
Q: What information is required on Form CA-1122?
A: Form CA-1122 requires information such as the claimant's name, date of injury, nature of injury, and the amount of recovery sought.
Form Details:
- Released on May 1, 2015;
- The latest available edition released by the U.S. Department of Labor;
- Easy to use and ready to print;
- Yours to fill out and keep for your records;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form CA-1122 by clicking the link below or browse more documents and templates provided by the U.S. Department of Labor.
Download Form CA-1122 Short Form Statement of Recovery
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