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November 4, 2008    DOL Home > Find It! By Form > DOL Form   

DOL Form LS-276

View ESA-OWCP-DLHWC's Form 1215-0204 Online htm
Agency: ESA-OWCP-DLHWC
Title: DLHWC (Longshore) LS-276, Application for Security Deposit Determination
Form Description: DLHWC (Longshore) LS-276, Application for Security Deposi Determination: An insurance carrier authorized to write insurance for payment of compensation under the Longshore and Harbor Workers' Compensation Act, 33 USC 901-950, or any of its extensions must fully secure its payment obligation under the statutes by depositng security in the amount determined by the Office of Workers' Compensation Programs. On annual basis, each authorized carrier (or a carrier seeking authorization) must complete this aplication. The information in this application will help the Office determine the security amount necessary to fully secure the carrier's payment of compensation, medical services and supplies, and any other obligations it has under these statutes.
OMB Control Number: 1215-0204
OMB Expiration Date: Thursday, September 30, 2010




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