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View ESA-OWCP-DLHWC's Form 1215-0112 Online 
| Agency: |
ESA-OWCP-DLHWC |
| Title: |
DLHWC (Longshore) LS-426, Request for Earnings Information |
| Form Description: |
DLHWC (Longshore) LS-426, Request for Earnings Information: This is a Department of Labor letterhead letter sent by the Longshore District Office to an injured worker to request information regarding earnings for the one year prior to the injury. The form is sent when the Department of Labor receives information from an insurance carrier or self insured employer that compensation is being paid at the minimum rate pending receipt of earnings information. |
| OMB Control Number: |
1215-0112 |
| OMB Expiration Date: |
Tuesday, June 30, 2009
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