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View ESA-OWCP-DLHWC's Form 1215-0073 Online 
| Agency: |
ESA-OWCP-DLHWC |
| Title: |
DLHWC (Longshore) LS-266, Application for Continuation of Death Benefit for Student |
| Form Description: |
DLHWC (Longshore) LS-266, Application for Continuation of Death Benefit for Student: This application is submitted by or on behalf of a dependent student 18 years or older to notify the Department of Labor and the self-insured employer/insurance carrier of the student's intentions to continue education beyond high school. The specific purpose of the form is to request continuation of compensation benefits during the time the student remains in school full-time, not to exceed their 23rd birthday. |
| OMB Control Number: |
1215-0073 |
| OMB Expiration Date: |
Monday, January 31, 2011
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