Longshore Program

 

 

 

OWCP's  Longshore Program has made the following forms available online. These forms are only available in 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 (click on Adobe Acrobat Reader to download the current version) available on your workstation. These forms can be viewed in an Internet Explorer browser window, but not in other browsers. If you are using Chrome or Firefox, follow these instructions to download PDF files and open them in Adobe Acrobat Reader.

The forms in the list below may be completed manually via the print form option or electronically via the electronic fill option:

Printable Forms

All of the Longshore Program's online forms (with the exception of Forms LS-241 and LS-242) are available to print and to manually fill and submit. Simply click on the appropriate form and print it using the [Print] button provided near the top of the form. Write or type the required information on the hardcopy and authorize the form, if applicable, with a hand-written signature. Then mail or fax the completed form to the Federal Employees Program office you normally send to for this process.

Fillable Forms

Forms (with the exception of Forms LS-241 and LS-242) may be electronically filled. Simply click on the appropriate form, fill out the form using your computer keyboard and the <TAB> key or your mouse to navigate between form fields. Print the form (use the Print button on or near the top of the form), authorize the form (if applicable provide hand-written signature) and mail or fax the completed form to the Federal Employees Program office you normally send to for this process.

NOTE: When printing these files please remember to use the Adobe Acrobat Reader print icon or the [Print] button on the form, itself, and NOT your browser's print icon on the browser toolbar.

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
 
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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.

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