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Office of Workers' Compensation Programs (OWCP)

Division of Longshore and Harbor Workers' Compensation (DLHWC)

DLHWC Longshore Forms

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OWCP's Division of Longshore and Harbor Workers' Compensation (DLHWC/Longshore) has made the following forms available online. Some of these forms are available in Adobe PDF format. In order to view and/or print PDF documents you must have a PDF viewer. It is highly recommended that you have the most current version of Adobe Reader available on your workstation. When printing these files, please use the Adobe Acrobat Reader print icon or the "Print" button on the form itself, NOT your browser's print icon on the browser toolbar.

Form Number	OWCP's Form Title/Description
LS-1	Request for Examination and/or Treatment
LS-18*	Pre-Hearing Statement *Online submission now available.
LS-33	Approval of Compromise of Third Person Cause of Action
LS-200	Report of Earnings
LS-201	Notice of Employee's Injury or Death
LS-202*	Employer's First Report of Injury or Occupational Illness *Online submission now available.
LS-203	Employee's Claim for Compensation
LS-204	Attending Physician's Supplementary Report
LS-205	Physician's Report on Impairment of Vision
LS-206*	Payment of Compensation Without Award *Online submission now available.
LS-207*	Notice of Controversion of Right to Compensation *Online submission now available.
LS-208*	Notice of Final Payment or Suspension of Compensation Payments *Online submission now available.
LS-210	Employer's Supplementary Report of Accident or Occupational Illness
LS-241 / LS-242	Notice to Employees Not currently available online. To inquire about this form please contact the Longshore National Office.
LS-262	Claim for Death Benefits
LS-265	Certification of Funeral Expenses
LS-266	Application for Continuation of Death Benefit for Student
LS-267	Claimant's Statement
LS-271	Application for Self-Insurance instructions
LS-272	Application to write Longshore Insurance (Carriers)
LS-274	Report of Injury Experience of Insurance Carrier or Self-Insured Employer
LS-275ic	Agreement and Undertaking (Insurance Carrier)
LS-275si	Agreement and Undertaking (Self-Insured Employer)
LS-276	Application for Security Deposit Determination. More information...
LS-426	Request for Earnings Information
LS-513	Report of Payments Not currently available online. To inquire about this form please contact the Longshore National Office.
LS-570	Card Report of Insurance Not currently available online. To inquire about this form please contact the Longshore National Office.
OWCP-5a*	Work Capacity Evaluation (Psychiatric/Psychological Conditions) *Online submission now available.
OWCP-5b*	Work Capacity Evaluation (Cardiovascular/Pulmonary Conditions) *Online submission now available.
OWCP-5c*	Work Capacity Evaluation (Musculoskeletal Conditions) *Online submission now available.

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How to Complete a Form

Longshore forms can now be completed using any one of the three options below including electronic submission for selected forms (LS-18, LS-202, LS-206, LS-207 and LS-208 forms). See below for detailed instructions:

OPTION 1 Print form

Select form
Print form using the "Print" button on or near the top of the form
Write/type in the required information
Authorize the form (if applicable) by providing a hand-written signature
Mail/fax to the appropriate Longshore District office

OPTION 2 Form-fill

Select form
Complete the form using your computer keyboard and the <TAB> key or your mouse to navigate between form fields
Print the form using the "Print" button on or near the top of the form
Authorize the form (if applicable) by providing a hand-written signature
Mail/fax to the appropriate Longshore District office

OPTION 3 Submit form electronically

Certain Longshore forms (noted with an asterisk (*)) may be completed electronically and submitted to Longshore. To do so, you must have Adobe Reader 6.x installed on your PC. Electronic form submission is limited to the appropriate Longshore District office destination only. If there are additional requirements to submit a copy of the Longshore form to other parties then these must be satisfied using existing distribution methods.

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How to Submit a Form Electronically

To electronically submit a Longshore form to a District office, follow these simple steps:

Upon opening the form you will be prompted to go to the IdenTrust Inc. Web site to obtain an electronic signature. Please be patient as it may take a few minutes for this prompt/box to appear. The entire process of obtaining the electronic signature will take 5-10 business days. You only have to do this one time, and, thereafter, you will use the same signature.
Fill out the form completely, making sure to fill in the required fields (marked with a red asterik (*)). You must fill in the required fields in order to submit the form.
Click on the "Submit" button on or near the top of the form. Select the appropriate district office. More information regarding jurisdiction.
Click on the "Submit" button again, you will be prompted to provide your electronic signature. Click anywhere in the signature box.
Click on the "Print" button to print a hard copy of the form for your records, then click the "Submit" button one last time to submit the form. A pop up box will appear noting that the form has been received and will provide an identification number. Please be patient, this pop-up box could take up to 2-3 minutes depending on your type of Internet connection. We recommend that you record the ID number on your hardcopy.

If you have questions about filling/submitting these forms or need other forms assistance, you can send Longshore a question via e-mail at DLHWC-Public@dol.gov. Longshore will respond to your question via e-mail.