Form LS-206 Payment of Compensation without Award

Payment Of Compensation Without Award

U.S. Department of Labor

(Longshore and Harbor Workers' Compensation Act,

Office of Workers' Compensation Programs

as extended)

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OMB No. 1240-0043

NOTE: This Notice is to be filed with the District Director not later
than the same day that first payment is made. A copy should
be sent to the payee(s) AND to their attorney (if represented).

1. OWCP No.

FOR OFFICE USE
2. CARRIER'S No.

3. Name of injured person (First, middle, last - please print or type)

4. Address of injured person (Number, street, city, state and ZIP code)

United States
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

8.

multiplied by 2/3 compensation rate $

Average weekly wage $

(Mark if maximum rate is being paid)

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

Yes

No

9a. For DBA cases only, is the employer continuing to pay the
injured person's salary?
Yes

until notice is given that payment has been stopped or suspended

No

9b. If so, are these salary continuation payments being made in
lieu of compensation payments?

I0. Date of first payment (Month, day, year.)

Yes

No

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)

United States
13. Name and address of insurance carrier and/or claim administrator(Name, number, street, city, state, ZIP code and country)

United States
14. Authorized signature

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

Phone number

16. Date signed(mm-dd-yyyy)

Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection
displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 10 minutes per response,
including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Use of this form is optional, however furnishing the information is required in order to obtain and/or
retain benefits (20CFR 702.317). Send comments regarding the burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the U.S. Department of Labor, Room C4315, 200 Constitution Avenue, NW, Room C-4315,
Washington, D.C. 20210, and reference the OMB Control Number.
DO NOT SEND COMPLETED FORMS TO THIS OFFICE.
Form LS-206
Rev. August 2011