DLHWC Longshore Forms | U.S. Department of Labor

Division of Longshore and Harbor Workers' Compensation (DLHWC)

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 forms, Please use the PRINT BUTTON on the form itself. It is located in the TOP LEFT corner of the form. DO NOT use your browser's print icon on the browser toolbar. For further instruction on completing and printing forms please click here.

Division of Longshore and Harbor Workers' Compensation Program (Longshore) Forms
Form Number	OWCP's Form Title/Description
LS-1	Request for Examination and/or Treatment
LS-4	Attorney Fee Approval Request
LS-5	Application for Special Fund Relief
LS-6	Commutation Application
LS-7	Request for Intervention
LS-8	Settlement Approval Request 8(i)
LS-9	Stipulation Approval Request
LS-18	Pre-Hearing Statement
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
LS-203	Employee's Claim for Compensation
LS-204	Attending Physician's Supplementary Report
LS-207	Notice of Controversion of Right to Compensation
LS-208	Notice of Payments
LS-210	Employer's Supplementary Report of Accident or Occupational Illness
LS-241 / LS-242	Notice to Employees (This form is provided by the Insurance Carrier when the policy is issued. Employers should request from their carrier. Carriers and self-insurers should request from their corporate compliance department.)
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	Agreement and Undertaking (Insurance Carrier)
LS-275si	Agreement and Undertaking (Self-Insured Employer)
LS-276	Application for Security Deposit Determination. State Guarantee Fund Longshore Security Factor Chart
LS-426	Request for Earnings Information
LS-513	Report of Payments.
LS-570	Carrier's Report of Issuance of Policy (formerly Card Report of Insurance)
LS-801	Waiver of Service by Registered or Certified Mail for Employers and/or Insurance Carriers
LS-802	Waiver of Service by Registered or Certified Mail for Claimants and Authorized Representatives
OWCP-5a	Work Capacity Evaluation (Psychiatric/Psychological Conditions)
OWCP-5b	Work Capacity Evaluation (Cardiovascular/Pulmonary Conditions)
OWCP-5c	Work Capacity Evaluation (Musculoskeletal Conditions)
OWCP-16	Rehabilitation Plan And Award
OWCP-17	Rehabilitation Maintenance Certificate
OWCP-44	Rehabilitation Action Report

How to Complete a Form

Longshore forms can now be completed using any one of the two options. 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 to the Longshore Central Mail Receipt 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 to the Longshore Central Mail Receipt office.

If you have questions about filling/submitting these forms or need other forms assistance, please visit our Frequently Asked Questions, or alternatively you can send Longshore a question via e-mail at DLHWC-Public@dol.gov. Longshore will respond to your question via e-mail.