skip navigational linksDOL Seal - Link to DOL Home Page
Photos representing the workforce - Digital Imagery´┐Ż copyright 2001 PhotoDisc, Inc.
www.dol.gov/esa
November 5, 2008    DOL Home > ESA > OWCP > DLHWC > DLHWC Forms   

Office of Workers' Compensation Programs (OWCP)

Printer-Friendly Version

ESA OFCCP OLMS OWCP WHD
OWCP Administers disability compensation programs that provide benefits for certain workers or dependants who experience work-related injury or illness.
Black Lung Longshore Energy Federal Employees' Comp line graphic


Division of Longshore and Harbor Workers' Compensation (DLHWC)

DLHWC Longshore Forms

On This Page

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 New

Agreement and Undertaking (Insurance Carrier)


LS-275si New

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.

Back to Top Back to Top

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.
Back to Top Back to Top

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.

 



Phone Numbers