Office of Workers' Compensation Programs (OWCP)
Division of Longshore and Harbor Workers' Compensation (DLHWC)
CHAPTER 10-200 FORMS
FORM NO. |
EXHIBIT NO. |
TITLE |
DISTRIBUTION |
PM REFERENCE |
LS-1 |
1 |
Request for Examination and/or Treatment |
|
5-200.3 |
LS-3 |
2 |
District Office Statistical Report |
Orig: NO |
9-200 |
LS-3s |
3 |
Supplemental Statistical Report and Definitions for Form LS-3s |
Orig: NO |
9-300 |
OWCP-14 |
4 |
Referral to OWCP Rehabilitation |
Distribute Copies As Shown on Form |
3-301.3g |
LS-18 |
5 |
Pre-Hearing Statement |
To All Parties |
4-200.10,
|
LS-19 |
6 |
Certificate of Filing and Service (for use with ALJ orders) |
Orig: Case File |
4-600.8b |
LS-19a |
7 |
Certificate of Filing and Service (for use with DD orders) |
Orig: Case File |
4-200.9c, |
LS-20 |
8 |
Notification of ALJ Decision |
Orig: All Parties |
4-600.8c |
LS-21 |
9 |
Guidance for Completion of LS-18 |
To All Parties |
4-600.3a |
LS-33 |
10 |
Approval of Compromise of Third Person Cause of Action |
Orig: Claimant |
3-600.2 |
CA-58 |
11 |
Case File Transfer |
Orig: Case File |
1-501.4a |
CA-67 |
12 |
Case File Transmittal Sheet |
Orig: Receiving Office |
1-501.4c |
LS-141 |
13 |
Notice of Informal Conference |
To All Parties |
4-200.5a(2), |
LS-200 |
14 |
Report of Earning |
Disability Benefit Recipients |
6-300.2 |
LS-201 |
15 |
Notice of Employee's Injury or Death |
|
15
1-400.3, |
LS-202 |
16 |
Employer's First Report of Injury or or Occupational Disease |
|
16
1-400.3, |
LS-203 |
17 |
Employee's Claim for Compensation |
|
1-400.3, |
LS-204 |
18 |
Attending Physician's Supplementary Report |
|
1-400.3, |
LS-206 |
19 |
Payment of Compensation Without Award |
|
1-400.3, |
LS-207 |
20 |
Notice of Controversion of Right to Compensation |
|
2-201.3d, |
LS-208 |
21 |
Notice of Final Payment or Suspension of Compensation Payments |
|
1-400.3, |
LS-209 |
22 |
Request for Employee's Reply to Employer's Objections |
Orig: Claimant |
2-201.3d, |
LS-210 |
23 |
Employer's Supplementary Report of Accident or Occupational Illness |
|
2-201.2h |
LS-215a |
24 |
Notice to Employer and Insurance Carrier That Claim Has Been Filed |
Orig: EC |
2-201.4 |
LS-216 |
25 |
Request for Additional Reports |
Orig: EC |
3-301.3e(3), |
LS-222 |
26 |
Carrier's or Self Insurer's Report on Rehabilitation to Deputy Commissioner |
Distribute Copies As Shown on Form |
3-301.3g |
LS-226a |
27 |
Subpoena Duces Tecum |
To Any Party |
4-400.11 |
LS-239 |
28 |
Compensation Certificate |
Orig: To Employer |
7-500.5 |
LS-240 |
29 |
Compensation Certificate for Self-Insured Employers |
Orig: To Self-Insured Employer cc: DO Insurance Section |
7-500.5 |
LS-241 |
30 |
Notice to Employees |
Orig: To Employer |
|
LS-242 |
31 |
Notice to Employees (for Self-Insured Employers) |
Orig: To Employer |
|
LS-262 |
32 |
Claim for Death Benefits |
|
1-400.3, |
LS-265 |
33 |
Certification of Funeral Expenses |
|
2-202.3, |
LS-266 |
34 |
Application for Continuation of Death benefit for Student |
|
2-202.3, |
LS-267 |
35 |
Claimant's Statement |
Death Benefit Recipients |
6-300.2 |
LS-274 |
36 |
Report of Injury Experience |
|
7-400.8a |
LS-280 |
37 |
Memorandum of Informal Conference |
Orig: Case File |
4-200.8, |
LS-403 |
38 |
Employee's Right to File Claim for Disability Compensation |
Orig: To Claimant |
2-201.2f, |
LS-426 |
39 |
Request to Employee for Wage Earnings Information |
Orig: To Claimant |
2-201.3b, |
LS-504 |
40 |
Letter to Employee Explaining Rights |
Orig: To Claimant |
1-400.3d, |
LS-512 |
41 |
Request to Employer for Form LS-202 |
Orig: To Employer |
8-302.5d |
LS-521 |
42 |
Annual Adjustment of Award |
Orig: EC |
3-202.5b |
LS-526 |
43 |
Letter to Employee Explaining Need for Employer's Approval of Third Party Settlement |
Orig: To Claimant |
3-600.2 |
LS-535 |
44 |
Notice to Guardian of Provision for Benefit Continuation |
Orig: To Parent or Guardian cc: EC, Case File |
3-302.5a |
LS-536 |
45 |
Notice to Guardian of Requirement to Complete Form LS-266 |
Orig: To Parent or Guardian cc: EC, Case File |
3-302.5b |
LS-537 |
46 |
Notice of Recommended Change in Compensation Based on Higher AWW |
Orig: EC |
3-201.8a, |
LS-541 |
47 |
Recommendation to EC to Accept Continuation of Death Benefits |
Orig: EC |
3-302.5c |
LS-548 |
48 |
Letter Explaining EC's Responsibility to File Timely LS-202 |
Orig: To Employer |
8-302.4b |
LS-551 |
49 |
Notice Assessing Penalty for Late Filing of Form LS-202 |
Orig: To Employer |
8.302.5d |
LS-552 |
50 |
Notice to EC of Penalty for Late Filing of Form LS-208 |
Orig: To Employer |
8-301.6d |
LS-557 |
51 |
Notice to Employee of Compensation Rate Under LHWCA |
Orig: To Claimant |
2-201.3b |
LS-570 |
52 |
Card Report of Insurance |
|
7-300.8, |
|
53 (Reserved) |
|
|
|
AR-10 |
54 |
Corrective Action Report |
Orig: To Office of Management, Administration, and Planning |
9-500.3c, |
|
55 (Reserved) |
|
|
|
DL 1-301 |
56 |
Cash Receipts Register |
Orig: Remains in DO |
1-200.9e, |
DL 1-303 |
57 |
Cash Transfer Receipt |
Orig: Remains in DO |
1-200.9f, |
|