Defense Base Act Longshore Forms





LS-1


Request for Examination and/or Treatment


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-205


Physician's Report on Impairment of Vision




LS-206


Payment of Compensation Without Award





LS-207


Notice of Controversion of Right to Compensation




LS-208


Notice of Final Payment or Suspension of Compensation 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
Not currently available online. To inquire about this form please contact the Longshore National Office.




LS-570


Carrier's Report of Issuance of Policy (formerly Card Report of Insurance)




OWCP-5a

Work Capacity Evaluation (Psychiatric/Psychological Conditions)




OWCP-5b

Work Capacity Evaluation (Cardiovascular/Pulmonary Conditions)




OWCP-5c

Work Capacity Evaluation (Musculoskeletal Conditions)


How to Complete a Form

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:

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/fax to the appropriate Longshore District 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/fax to the appropriate Longshore District office

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