LS-203 Employee's Claim for Compensation

U.S. Department of Labor

Employee's Claim for Compensation
See Instructions On Reverse

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Office of Workers' Compensation Programs

Reset

OMB No.1240-0014

3. Name of person making claim (Type or print)
MI. Last
First

1. OWCP No.

Telephone No.

5. Claimant's address (number, street, city, state, ZIP code)

2. Carrier's No.
4. Date of Injury

city:
state:

line1:

zip code:

6. Marital Status
Married

country: United States

line2:

7. Sex
Male

Female

8. Date of Birth

11. Date and time of accident.

(mm/dd/yyyy)

13. Date and hour you returned to work
(mm/dd/yyyy)

9. Social Security # (Required
by law)

(hh:mm am/pm)

16. Wages or earnings when injured
(include overtime allowances, etc.)

(hh:mm am/pm)

11a. Did you stop work immediately?

12. Date and hour pay stopped?
(mm/dd/yyyy)

No

a. Weekly

b. Total earnings during year immediately
before injury.

21. Earliest date supervisor or employer knew of accident
(mm/dd/yyyy)

(hh:mm am/pm)

15. Injured while doing regular work?
Yes
No
(if "No," explain in Item 24)

14. Occupation (Job title: longshore worker, welder, etc.)

19. Number of days usually
worked per week

18. Number of years you worked
for this employer

10. Did injury. cause loss of time beyond day
or shift of accident?
Yes
No

9a. Nationality

Yes

Single

17. Has 3rd party or other claim been made
because of this Injury?
No
Yes

20. Name of supervisor at time of accident?
22. Were you employed elsewhere during the week injured?
(If "Yes," state where and when on reverse.)
Yes
No

23. Exact place where accident occurred (Street address, city, town, name of vessel, pier, terminal, etc.)

24. Describe in full how the accident occurred (Relate the events which resulted in the injury or occupational disease. Tell what the injured was
doing at the time of the accident. Tell what happened and how it happened. Name any objects or substances involved and tell how they
were involved. Give full details on all factors which led or contributed to the accident. If more space is needed, continue on reverse.)

25. Nature of injury (name part of
body affected - fractured left leg,
bruised right thumb, etc. If there
was a loss or loss of use of a part
of the body. describe.)
26. Have you received medical attention for this injury?
(if *Yes," give name and address of doctor, clinic, hospital, etc.)

Yes

No

27. Were you treated by a physician of
your choice?
Yes

28. Was such treatment provided by employer?
Yes

No

29. Are you still disabled on account of this injury?
Yes
No

31. Have you received any wages since becoming disabled?
Yes

No

(if "Yes," give dates on reverse)

33. Name of employer (individual or firm name)
35. Address of employer (Number, street, city, state, ZIP code)

30. Have you worked during the period
of disability?

Signature of claimant
or person acting in his/her behalf

No

Yes

32. Has injury resulted in permanent disability, amputation or serious
disfigurement?
No
Yes (Describe on reverse.)
34. Nature of employer's business
36. If accident occurred outside the U.S.,
state whether you are a U.S. Citizen

Yes
37. I hereby make claim for compensation benefits,
monetary and medical, under the

No

No

38. Date of this claim
(mm/dd/yyyy)

Section 31(a)(1) of the Longshore Act. 33 U.S.C. 931(a)(1) provides. as follows: Any claimant or representative of a claimant
who knowingly and willfully makes a false statement or representation for the purpose of obtaining a benefit or payment under
this Act shall be guilty of a felony, and on conviction thereof shall be punished by a fine not to exceed $10,000, by
imprisonment not to exceed five years, or by both.
Form LS-203

Rev. March 2012

Instructions
• Use this form to file a claim under any one of the following laws:
Longshore and Harbor Workers' Compensation Act
Defense Base Act
Outer Continental Shelf Lands Act
Nonappropriated Fund Instrumentalities Act

- Applicant may leave items 1. and 2. blank.
Except as noted below, a claim may be filed within one year after the injury or death (33 U.S.C. 913(a)). If compensation has been paid

without an award, a claim may be filed within one year after the last payment. The time for filing a claim does not begin to run until the
employee or beneficiary knows, or should have known by the exercise of reasonable diligence, of the relationship between the employment
and the injury. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
The information will be used to determine an injured worker's entitlement to compensation and medical benefits.
In case of hearing loss, a claim may be filed within one year after receipt by an employee of an audiogram, with the accompanying report
thereon, indicating that the employee has suffered a loss of hearing.
In cases involving occupational disease which does not immediately result in death or disability, a claim may be filed within two years after
the employee or claimant becomes aware, or in the exercise of reasonable diligence or by reason of medical advice should have been
aware, of the relationship between the employment, the disease, and the death or disability.
To file a claim for compensation benefits, complete and sign two copies of this form and send or give both copies to the Office of Workers'

Compensation Programs District Director in the city serving the district where the injury occurred. District Offices of OWCP are located In the
following cities.
Baltimore
Boston
Chicago

Honolulu
Houston
Jacksonville
Long Beach

New Orleans
New York
Norfolk

Philadelphia
San Francisco
Seattle
Washington, D.C.

Use the space below to continue answers. Please number each answer to correspond to the number of the item being continued.

Privacy Act Notice

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a) you are hereby notified that (1) the Longshore and Harbor Workers'
Compensation Act, as amended and extended (33 U.S.C. 901 et seq.) (LHWCA) is administered by the Office of Workers' Compensation Programs
of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information which
the Office has will be used to determine eligibility for and the amount of benefits payable under the LHWCA. (3) Information may be given to the
employer which employed the claimant at the time of injury, or to the insurance carrier or other entity which secured the employer's compensation
liability. (4) Information may be given to physicians and other medical service providers for use in providing treatment or medical/vocational
rehabilitation, making evaluations and for other purposes relating to the medical management of the claim. (5) Information may be given to the
Department of Labor's Office of Administrative Law Judges (OALJ), or other person, board or organization, which is authorized or required to render
decisions with respect to the claim or other matter arising in connection with the claim. (6) Information may be given to the Federal, state and local
agencies for law enforcement purposes, to obtain information relevant to a decision under the LHWCA, to determine whether benefits are being or
have been paid properly, and where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by law. (7)
Disclosure of the claimant's Social Security Number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN and other
information maintained by the Office may be used for identification, and for other purposes authorized by law. (8) Failure to disclose all requested
information may delay the processing of the claim, the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.
Note: The notice applies to all forms requesting information that you might receive from the Office in connection with the processing
and/or adjudication of the claim you filed under the LHWCA and related statutes.

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 15 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. ( 33 U.S.
C.913(a) ). 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, 200 Constitution Avenue, NW, Room C-4315, Washington, D.C. 20210, and reference the OMB
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
Control Number.