Longshore Harbor Workers Compensation Act

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LHWCA Claims Forms Explained

Under the Longshore and Harbor Workers' Compensation Act, there are different forms which must be used by the Employer and Employees. These forms are available online at www.dol.gov. The completed forms must be submitted to the appropriate Longshore District Office.

Form LS 1 (www.dol.gov) is used by employers to authorize medical treatment for injured workers and by physicians to report findings of physical examinations and treatment recommended.

Form LS18 (www.dol.gov) is used to refer cases to Administrative Law Judges for formal hearings under the Act. This form can be submitted online.

Form LS 33 (www.dol.gov) is the document which records the compromise in a third person cause of action.

Form LS 200 (www.dol.gov) is used to verify continued entitlement of claimants to receive death benefits from Special Fund.

Form LS 201 (www.dol.gov) is used by an employee or beneficiary to provide written notice of injury or death.

Form LS 202 (www.dol.gov) and Form LS 210 (www.dol.gov) are used to report injuries, periods of disability, and medical treatment.

Form LS 202 can be submitted online.

Form LS 203 (www.dol.gov) is to be completed by injured claimants.

Form LS 204 (www.dol.gov) is completed by physicians rendering treatment and filed by the district office with a copy sent to the responsible employer/insurance carrier.

Form LS 205 (www.dol.gov) is the medical report pertaining to the impairment of vision.

Form LS 206 (www.dol.gov) is used by insurance carriers and self-insurers to report the start of compensation benefits. This form can be submitted online.

Form LS 207 (www.dol.gov) is used by insurance carriers and self-insured employers to controvert claims under the Act. This form can be submitted online.

Form LS 208 (www.dol.gov) is used to notify OWCP District Officers that payment of compensation benefits has been stopped or suspended in a case. This form can be submitted online.

Forms LS 241 and LS 242 are forms of notices to employees but they are not available online. They can be obtained from the Longshore National Office.

Form LS 262 (www.dol.gov) is used by all classes of dependents to file death claims.

Form LS 265 (www.dol.gov) is used to report funeral expenses.

Form LS 266 (www.dol.gov) is used as an application for continuation of death benefits for a dependent who is a student.

Form LS 267 (www.dol.gov) is used to verify the continued entitlement of claimants to received death benefits from the Special Fund.

Form LS 271 (www.dol.gov) is used to collect basic information concerning the applicant's type of business, number of employees, accident experience and type of excess insurance coverage.

Form LS 272 (www.dol.gov) is the application to write longshore insurance and must be made by insurance companies or carriers seeking permission to write longshore insurance.

Form LS 274 (www.dol.gov) requires that self-insured employers authorized under the Act provide to the OWCP on request a report showing all outstanding injury and death cases.

Forms LS 275ic (www.dol.gov) and LS 275si (www.dol.gov) are the agreement and undertaking to be executed by insurance carriers and self insured employer respectively.

Forms LS 276 (www.dol.gov) is the application for security deposit determination.

Form LS 426 (www.dol.gov) is used to verify the average weekly wage of an injured employee to determine if the correct compensation rate is being paid.

Form LS 513 is CONTROLLED USE DOCUMENT issue by Longshore National Office only and released only to those insurance carriers and self-insured employers authorized by DOL to write insurance coverage or be self-insured under the Longshore Act. It is the report of payments.

Form LS 570 is only available from the Longshore National Office and is the card report of insurance.

Form OWCP 5a (www.dol.gov) is the form for evaluation of work capacity of the employee (Psychiatric/Psychological Conditions), Form OWCP 5b (www.dol.gov) is for Cardiovascular/Pulmonary Conditions and Form OWCP 5c (www.dol.gov) is for Musculoskeletal Conditions.

Longshore & Harbor Workers Compensation Act (LHWCA)

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