Notice of Final Payment or Suspension of Compensation Benefits

U.S. Department of Labor

Notice of Final Payment or Suspension
of Compensation Payments
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Employment Standards Administration
Office of Workers' Compensation Programs

Submit

INSTRUCTIONS: This notice must be filed in triplicate with the District Director of the OWCP OMB No.: 1215-0024
within 16 days after compensation has been stopped or suspended. (33 U.S.C. 914(g). If
1. OWCP No.
payments have stopped temporarily, or are being modified, and will be reinstated, or
payments are being continued, indicate in item 11, and give reasons. This form is to be used
2. Carrier's No.
for reporting either disability or death benefit payments. The information will be used to
verify compensation paid under the Act. Persons are not required to respond to this
collection of information unless it displays a currently valid OMB control number.

3. Name and address of Employee or other beneficiary (Type or print)
Place within brackets
* Last Name
*

* First Name

line 1:

city:

line 2:

st:

a. OFFICE OF THE DISTRICT DIRECTOR
U.S. DEPT. OF LABOR-OWCP

M.I.
country

4. Name of employer *

6. Date of Injury *

CARRIER - Send copies 1, 4 and 5
to the District Director, who will
forward employee's copy.

zip:

5. Address of employer

7. Date employee first lost pay because of injury

9. Date employee returned to work

8. Date physician found employee able to return to work

10. Was compensation paid at the maximum rate? *

Yes

No

*multiplied by 2/3 =
Compensation rate $

Average weekly wage $
11. State reason or reasons for termination or suspension of payments *

*

12. Date last payment made
13. Date of this notice *
07/14/2008

14.

ENTER ALL DISABILITY PAYMENTS

TYPE OF DISABILITY
a
Temporary total
Temporary partial
Temporary partial*
Permanent partial (Non-schedule)
Permanent total
Permanent partial
(Schedule loss, facial or other
disfigurement)

FROM
(Mo., day, yr.)
b

Percent

TO
(Mo., day, yr. incl.)
c

AMOUNT PAID
PER WEEK
d

NUMBER OF
WEEKS PAID
e

TOTAL
f

Part of body

*Report on this line payment for different period or rate than payments reported in previous line. TOTAL
ENTER ALL PAYMENTS MADE ON ACCOUNT OF DEATH
15.

b. AMOUNT

a. NAMES OF DEPENDENTS

(Attach continuation sheet)
16.

c. OTHER EXPENSES
Funeral expense
No dependents-paid to treasurer, U.S. [Sec. 44(C)(1)]

d. AMOUNT

TOTAL (cols. b + d)
ENTER OTHER PAYMENTS

a. Attorney fees
b. Penalty for late payment

c. Interest
TOTAL (cols. a, b, c)

17. Name of insurance carrier or self-insured employer *
18. Signature of person authorized to sign for carrier

a. Address of insurance carrier
19. Name and Title of person whose signature appears in item 18 *

Signature

EMPLOYEE PLEASE
READ
CAREFULLY

Any claim for compensation, to be valid, must be filed IN WRITING with the District Director, OWCP, WITHIN ONE YEAR after the
date of injury or date of last payment of compensation. If you have serious disfigurement of the face, head, or neck or other normally
exposed areas which may handicap you in securing or maintaining employment, or any impairment of the body or other disability
from the injury for which you have not received compensation, you should inform the District Director. (Address in 3a above)

Public Burden Statement
We estimate that it will take an average of 15 minutes to complete this collection of information, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If
you have any comments regarding these estimates or any other aspect of this collection of information, including suggestions for reducing
this burden, send them 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
1 - District Director
4 - Employee

2 - Employer
5 - Employee's Representative

3 - Insurance Carrier

Form LS-208
Rev. June 1998