Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0005 can be found here:

Documents and Forms

Document Name Document Type
Form LS-275-IC Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions Form
LS-275-IC Agreement and Undertaking (Insurance Carrier) LS-275ic.pdf www.dol.gov/esa/owcp/dlhwc/lsforms.htm Form
LS-275-SI Agreement and Undertaking (Self-Insured Employer) LS-275si.pdf www.dol.gov/esa/owcp/dlhwc/lsforms.htm Form
LS-276 Application for Security Deposit Determination LS-276.pdf www.dol.gov/esa/owcp/dlhwc/lsforms.htm Form
NOTE TO REVIEWER 1215-0204.doc Note to Reviewer for 1215-0204 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 703.204 20 CFR 703.303 20 CFR 703.205 20 CFR 702.210 20 CFR 703.212 20 CFR 703.304 20 CFR 703.2 20 CFR 703.203 20 CFR 703.209

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Electronic Capability
Form	LS-275-IC	Agreement and Undertaking (Insurance Carrier)	LS-275ic.pdf	http://www.dol.gov/esa/owcp/dlhwc/lsforms.htm	No	Fillable Printable
Form	LS-275-SI	Agreement and Undertaking (Self-Insured Employer)	LS-275si.pdf	http://www.dol.gov/esa/owcp/dlhwc/lsforms.htm	No	Fillable Printable
Form	LS-276	Application for Security Deposit Determination	LS-276.pdf	http://www.dol.gov/esa/owcp/dlhwc/lsforms.htm	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 646	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	646	-82	728
Annual IC Time Burden (Hours)	434	-36	470
Annual IC Cost Burden (Dollars)	288	288	0

Documents for IC

Title	Document	Date Uploaded
Note to Reviewer for 1215-0204	NOTE TO REVIEWER 1215-0204.doc	03/05/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.