Information Collection

Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act

IC 43808 under ICR 201202-1240-003 · OMB 1240-0014.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0014 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ESA 100.doc	Other-Recordkeeping
LS-201 Notice of Employee's Injury or Death ls-201 dev.pdf www.dol.gov/owcp/dlhwc/ls-201.pdf	Form
LS-513 Report of Payments LS-513.pdf	Form
LS-267 Claimant's Statement LS-267 dev.pdf www.dol.gov/owcp/dlhwc/LS-267.pdf	Form
LS-203 Employee's Claim for Compensation ls-203 dev.pdf www.dol.gov/owcp/dlhwc/ls-203.pdf	Form
LS-262 Claim for Death Benefits ls-262 dev.pdf www.dol.gov/owcp/dlhwc/ls-262.pdf	Form
LS-271 Application for Self-Insurance LS-271 dev.pdf www.dol.gov/owcp/dlhwc/LS-271.pdf	Form
LS-204 Attending Physician's Supplementary Report ls-204 dev.pdf www.dol.gov/owcp/dlhwc/ls-204.pdf	Form
LS-274 Report of Injury Experience of Insurance Carrier or Self LS-274 dev.pdf www.dol.gov/owcp/dlhwc/LS-274.pdf	Form
LS-200 Report of Earnings ls-200 dev.pdf www.dol.gov/owcp/dlhwc/ls-200.pdf	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act

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 702.174 20 CFR 702.242 20 CFR 702.285 20 CFR 702.321 20 CFR 702.175 20 CFR 702.202 20 CFR 702.221 20 CFR 702.201 20 CFR 702.111 20 CFR 703.310 20 CFR 702.162

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-204	Attending Physician's Supplementary Report	ls-204 dev.pdf	http://www.dol.gov/owcp/dlhwc/ls-204.pdf	Yes	No	Fillable Printable
Form	LS-200	Report of Earnings	ls-200 dev.pdf	http://www.dol.gov/owcp/dlhwc/ls-200.pdf	Yes	No	Fillable Printable
Other-Recordkeeping			ESA 100.doc		No		Paper Only
Form	LS-201	Notice of Employee's Injury or Death	ls-201 dev.pdf	http://www.dol.gov/owcp/dlhwc/ls-201.pdf	Yes	No	Fillable Printable
Form	LS-513	Report of Payments	LS-513.pdf		No		Paper Only
Form	LS-267	Claimant's Statement	LS-267 dev.pdf	http://www.dol.gov/owcp/dlhwc/LS-267.pdf	Yes	No	Printable Only
Form	LS-203	Employee's Claim for Compensation	ls-203 dev.pdf	http://www.dol.gov/owcp/dlhwc/ls-203.pdf	Yes	No	Fillable Printable
Form	LS-262	Claim for Death Benefits	ls-262 dev.pdf	http://www.dol.gov/owcp/dlhwc/ls-262.pdf	Yes	No	Fillable Printable
Form	LS-274	Report of Injury Experience of Insurance Carrier or Self-Insured Employer	LS-274 dev.pdf	http://www.dol.gov/owcp/dlhwc/LS-274.pdf	Yes	No	Fillable Printable
Form	LS-271	Application for Self-Insurance	LS-271 dev.pdf	http://www.dol.gov/owcp/dlhwc/LS-271.pdf	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/ESA-15

FR Citation: 67 FR 16886

Number of Respondents: 130,036

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	130,036	-45,338	175,374
Annual IC Time Burden (Hours)	44,950	-21,594	66,544
Annual IC Cost Burden (Dollars)	45,979	-20,608	66,587

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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