Form LS-206 Payment of Compensation without Award

Payment Of Compensation Without Award

U.S. Department of Labor

(Longshore and Harbor Workers' Compensation Act,
as extended)

Employment Standards Administration
Office of Workers' Compensation Programs

Print

Reset

OMB No. 1215-0022

Submit

NOTE: This Notice is to be filed with the District Director when the
first payment is made. A copy should be sent to the
payee(s) AND to their attorney.

FOR OFFICE USE
2. CARRIER'S No.

1. OWCP No.

3. Name of injured person (First, middle, last - please print or type)
Last Name *
First Name *
M.I.
4. Address of injured person (Number, street, city, state and ZIP code) *
line 1:

city:

line 2:

state:

country:
zip:

6. Date disability began (Month, day, year)

5. Date of accident or first illness (Month, day, year)

7. Name of injured, or dependents of injured, to whom compensation will be paid
Last Name *
First Name *
M.I.

8.

*

multiplied by 2/3 compensation rate $

Average weekly wage $

(Mark if maximum rate is being paid)

Yes

No

9. Compensation will be paid from - Enter month, day, year. *

until notice is given that payment has been stopped or suspended
I0. Date of first payment (Month, day, year.) *

11. Has medical care and treatment been provided by a physician or hospital chosen by the injured person? *
(Mark appropriate box)
Yes
No
12. Name and address of employer (Name, Number, street, city, state, ZIP code and country) *
name:
line 1:
line 2:

city:
state:

country:
zip:

13. Name and address of insurance carrier and/or claim administrator(Name, Number, street, city, state, ZIP code and country) *
name:
line 1:
line 2:

city:
state:

country:

zip:

14. Authorized signature *

Signature
15. Type or print title and name of person whose signature appears in item 14 *

Phone Number

16. Date signed(mm-dd-yyyy) *
05/15/2008

Public Burden Statement
The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended.
The authority for requesting the following information is 20CFR 702.234. Use of this form is optional, however furnishing the information is required
in order to obtain and/or retain benefits. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 1215-0022. The time required to complete this information collection is estimated to average 15 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to the U.S.Department of Labor, Division of Longshore and Harbor Workers' Compensation, Room C4315, 200 Constitution Avenue,
N.W, Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
Form LS-206
Rev. June 1997