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View ESA-OWCP-DLHWC's Form 1215-0027 Online 
| Agency: |
ESA-OWCP-DLHWC |
| Title: |
DLHWC (Longshore) LS-265, Certification of Funeral Expenses |
| Form Description: |
DLHWC (Longshore) LS-265, Certification of Funeral Expenses: This form is submitted by the provider of funeral services to notify the Department of Labor and self-insured employer/insurance carrier of the costs of funeral services for a deceased employee. It is used to determine the amount of funeral expenses allowable in a death case, subject to the maximum allowable. |
| OMB Control Number: |
1215-0027 |
| OMB Expiration Date: |
Monday, February 28, 2011
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