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.
Form Number |
OWCP's Form Title/Description |
---|---|
Request for Examination and/or Treatment |
|
Attorney Fee Approval Request |
|
Application for Special Fund Relief |
|
Commutation Application |
|
Request for Intervention |
|
Settlement Approval Request 8(i) |
|
Stipulation Approval Request |
|
Pre-Hearing Statement |
|
Approval of Compromise of Third Person Cause of Action |
|
Report of Earnings |
|
Notice of Employee's Injury or Death |
|
Employer's First Report of Injury or Occupational Illness |
|
Employee's Claim for Compensation |
|
Attending Physician's Supplementary Report |
|
Notice of Controversion of Right to Compensation |
|
Notice of Payments |
|
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.) |
Claim for Death Benefits |
|
Certification of Funeral Expenses |
|
Application for Continuation of Death Benefit for Student |
|
Claimant's Statement |
|
Report of Injury Experience of Insurance Carrier or Self-Insured Employer |
|
Agreement and Undertaking (Insurance Carrier) |
|
Agreement and Undertaking (Self-Insured Employer) |
|
Application for Security Deposit Determination. State Guarantee Fund Longshore Security Factor Chart |
|
Request for Earnings Information |
|
Report of Payments. |
|
Carrier's Report of Issuance of Policy (formerly Card Report of Insurance) |
|
Waiver of Service by Registered or Certified Mail for Employers and/or Insurance Carriers |
|
Waiver of Service by Registered or Certified Mail for Claimants and Authorized Representatives |
|
Work Capacity Evaluation (Psychiatric/Psychological Conditions)
|
|
Work Capacity Evaluation (Cardiovascular/Pulmonary Conditions) |
|
Work Capacity Evaluation (Musculoskeletal Conditions) |
|
Rehabilitation Plan And Award |
|
Rehabilitation Maintenance Certificate |
|
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.