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 |
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Request for Examination and/or Treatment |
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Pre-Hearing Statement |
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Approval of Compromise of Third Person Cause of Action |
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Report of Earnings |
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Notice of Employee's Injury or Death |
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Employer's First Report of Injury or Occupational Illness |
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Employee's Claim for Compensation |
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Attending Physician's Supplementary Report |
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Physician's Report on Impairment of Vision |
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Payment of Compensation Without Award |
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Notice of Controversion of Right to Compensation |
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Notice of Final Payment or Suspension of Compensation Payments |
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Employer's Supplementary Report of Accident or Occupational Illness |
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LS-241 / LS-242 |
Notice to Employees |
Claim for Death Benefits |
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Certification of Funeral Expenses |
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Application for Continuation of Death Benefit for Student |
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Claimant's Statement |
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Report of Injury Experience of Insurance Carrier or Self-Insured Employer |
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Agreement and Undertaking (Insurance Carrier) |
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Agreement and Undertaking (Self-Insured Employer) |
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Application for Security Deposit Determination. More information... |
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Request for Earnings Information |
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LS-513 |
Report of Payments |
LS-570 |
Card Report of Insurance |
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. |
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
OPTION 2 Form-fill
OPTION 3 Submit form electronically
How to Submit a Form Electronically
To electronically submit a Longshore form to a District office, follow these simple steps:
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