Form LS-570 Carrier's Report of Issuance of Policy

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CARRIER’S REPORT OF
ISSUANCE OF POLICY

U.S. DEPARTMENT OF LABOR
Office of Workers’ Compensation Programs
Division of Longshore and Harbor Workers' Compensation

Form LS-570 is used by authorized carriers to report the policy of insurance issued for
each insured employer. This form is to be sent to the Deputy Commissioner in the
compensation district indicated by the employer’s address. Section 32 (a) of the
Longshore and Harbor Workers' Compensation Act (33 USC 932(a)), and its
extensions requires every employer to secure the payment of compensation under this
Act either (1) by insuring and keeping insured the payment of such compensation with
any insurance company authorized by the Secretary, to insure payment of
compensation under this Act; or (2) receiving an authorization from the Secretary to
pay such compensation directly.

1. Date

OMB No.: 1240-0004
Expiration Date: 12-31-2012

2. Jurisdiction (Act or Extension)
Longshore and Harbor Workers’ Compensation Act
Outer Continental Shelf Lands Act
Non-Appropriated Funds Instrumentalities Act

3. Insurance Carrier Name

Defense Base Act

Carrier Details
4. Carrier Federal Employer Identification
Number (FEIN)

5. Policy Number

Policy Details
6. Effective Date

8. Prior Policy Number

9. Governing Class

7. Expiration Date

10. Total Payroll

Employer Details
11. Employer Name and Address

12. Employer FEIN

13. Employer Phone Number

14. Authorized Signature

Title

Send completed form to USDOL/OWCP/DLHWC, Room C-4315, 200 Constitution Avenue,
N.W., Washington, D.C. 20210
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 5 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. (20 CFR 703.116).
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 Control Number.

Form LS-570
January 2010