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September 23, 2008    DOL Home > Find It! By Form > DOL Form   

DOL Form LS-275ic

View ESA-OWCP-DLHWC's Form 1215-0204 Online htm
Title: DLHWC (Longshore) LS-275ic, Agreement and Undertaking(Insurance Carrier)
Form Description: DLHWC (Longshore) LS-275(IC), Agreement and Undertaking (Insurance Carrier): This report is a mandatory (20 CFR 03.205) pledge agreement that is required from every authorized insurance carrier that is required to post a security deposit whenever they post the initial security or replace or renew any security that is on deposit with the Department of Labor Longshore Division. It is used to assure the carrier’s prompt payment of compensation, medical services supplies, and any other obligations it has under the statutes (30 USC 932 CFR 703.213).
OMB Control Number: 1215-0204
OMB Expiration Date: Thursday, September 30, 2010

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