|
View ESA-OWCP-DLHWC's Form 1215-0204 Online 
| Agency: |
ESA-OWCP-DLHWC |
| Title: |
DLHWC (Longshore) LS-275si, Agreement and Undertaking (Self-Insured Employer) |
| Form Description: |
DLHWC (Longshore) LS-271(SI), Agreement and Undertaking (Self-Insured Employer): This report is a mandatory (20 CFR 703.205) pledge agreement that is required from any company authorized to be a self-insured employer under the Longshore Act and its extensions whenever they post their initial security deposit or renew or replace any security on deposit with the Department of Labor Longshore Division. It is used to assure the self-insured employer’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
|
| |
|
