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](https://webarchive.library.unt.edu/web/20081105142955im_/http://www.dol.gov/esa/images/new7.gif)
|
Agreement and Undertaking (Insurance Carrier) |
LS-275si ![New](https://webarchive.library.unt.edu/web/20081105142955im_/http://www.dol.gov/esa/images/new7.gif)
|
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. |
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:
To electronically submit a Longshore form to a District office, follow
these simple steps: