Form LS-208 Notice of Final Payment or Suspension of Compensation Be

Notice of Final Payment or Suspension
of Compensation Payments
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U.S. Department of Labor
Office of Workers' Compensation Programs

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INSTRUCTIONS: This notice must be filed with the District Director at the address in 3(a) within 16
days after compensation has been stopped or suspended. A copy of the completed form must be
mailed to the claimant and the claimant's representative. Use of this form is mandatory. Failure to
timely file this form shall result in assessment of a penalty of $110.00. (33 U.S.C. 914(g)). This form is
to be used to report disability or death compensation payments, as well as other statutory payments.
The information will be used to verify the sufficiency of compensation paid under the Act.
3. Name and address of Employee or other beneficiary (Type or print)

Expires: xx/xx/xxxx
1. OWCP No.

2. Carrier's No.

3a. Central Mail Receipt site:
U.S. Department of Labor
Office of Workers' Compensation Programs
Division of Longshore and Harbor Workers' Compensation
400 West Bay Street, Suite 63A, Box 28
Jacksonville, FL 32202

Place within brackets

United States

or

Upload directly to the case file at: https://seaportal.dol-esa.gov

4. Name of employer

6. Date of Iniury

OMB No.: 1240-0041

5. Address of employer

7. Date employee first lost pay
because of injury

9. Date employee returned to work

7a. Date first check issued

8. Date physician found employee able
to return to work

10. Was compensation paid at the maximum rate?

Yes

No

multiplied by 2/3 = Compensation rate $

Average weekly wage $
11. State reason or reasons for termination or suspension of payments

12. Date last payment made
13. Date of this notice

14.

TYPE OF DISABILITY
a
Temporary total

ENTER ALL PAYMENTS MADE ON ACCOUNT OF DISABILITY
FROM
THROUGH
AMOUNT PAID
(Mo., day, yr.)
(Mo., day, yr.)
PER WEEK
b
c
d

NUMBER OF
WEEKS PAID
e

TOTAL
f

Temporary partial
Permanent partial (non-schedule)

Permanent partial (schedule loss)
Percent
Part of body
Permanent total
TOTAL PAID:

Attach continuation sheet to show additional periods, rates and amounts:

15.

ENTER ALL PAYMENTS MADE ON ACCOUNT OF DEATH
BENEFICIARY'S NAME
FROM
THROUGH
AMOUNT PAID
(Mo., day, yr.)
(Mo., day, yr.)
AND DATE OF BIRTH
PER WEEK
a
b
c
d

Attach continuation sheet to show additional beneficiary's periods, rates and amounts:

NUMBER OF
WEEKS PAID
e

TOTAL
f

TOTAL PAID:

ENTER OTHER PAYMENTS

16.
a. Section 8(i) Settlement: 1) Compensation
2) Medical benefits

e. Attorney fees

b. Compensation for late payment per Sec. 14(e) or (f)

f. Funeral Expenses

c. Interest

g. Sec. 44(c)(1) payment to the Special Fund

d. Disfigurement

h. Commutation

As verified by the signature below, this form was mailed to the claimant and claimant's representative.
17. Name of insurance carrier or self-insured employer and claim administrator

a. Address and phone number of person whose name is shown in Box 18

18. Signature of person authorized to sign for employer or carrier

19. Name and Title of person whose siqnature appears in Box 18

EMPLOYEEPLEASE
READ
CAREFULLY

Any claim for compensation, to be valid, must be filed IN WRITING with the District Director, OWCP, WITHIN ONE YEAR after
the date of injury or date of last payment of compensation. If you have any impairment of the body, serious disfigurement,
or other disability from the injury which may handicap you in securing or maintaining employment you should submit a claim
to the U. S. Department of Labor as shown in 3a above. Please be sure to include the OWCP Case Number. For further
instructions, please see the reverse side of this form.

Form LS-208

Rev. xxxxxxxxxxxxx

INSTRUCTIONS TO INJURED WORKER AND BENEFICIARY
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. 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.
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 Form LS-203, Employee's Claim for Compensation
or Form LS-262, Claim for Death Benefits. The forms can be obtained through the OWCP/DLHWC website at:
http://www.dol.gov/owcp/dlhwc/lsforms.htm or by your servicing district office. The contact information is
available on the OWCP/DLHWC website at: http://www.dol.gov/owcp/dlhwc/lscontactmap.htm.
Please be sure to include the OWCP Case Number and mail this form to the OWCP/DLHWC Central Mail
Receipt site at the following address:

U. S. Department of Labor
Office of Workers' Compensation Programs
Division of Longshore and Harbor Workers' Compensation
400 West Bay Street, Suite 63A, Box 28
Jacksonville, FL 32202

Or upload the claim directly to the case file using the Secure Electronic Access Portal (SEAPortal).
Access the SEAPortal directly at: https://seaportal.dol-esa.gov

PRIVACY ACT STATEMENT
Privacy Act of 1974 as amended (5 U.S.C. §552a), section §914(g) of Title 33 to the U.S. Code and 20 C.F.R. §702.235 authorizes collection of
this information. The purpose of this information is to determine the final payment of compensation regarding the beginning and ending dates of
payments, compensation rates, reason payments were terminated and types and amount of compensation payments under the Longshore and
Harbor Workers' Compensation Act and its extensions (LHWCA). Completion of this form is mandatory and failure to provide the information may
result in assessment of civil penalty (33 U.S.C. §914 (g)) against the employer. Additional disclosures of this information may be to: (1) The
claimant and/or his representative. (2) 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. (3) 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. (4) 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 and have been paid properly, and where appropriate, to pursue salary/administrative offset and debt
collection actions required or permitted by law. (5) Failure to disclose all requested information may delay the processing of the claim, the payment
of additional benefits, or may result in an unfavorable decision or reduced level of benefits.

PUBLIC BURDEN STATEMENT
The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. §522a) and the Paperwork Reduction Act of 1995, as
amended. The authority for requesting the following information is 20 C.F.R. §702.251. Use of this form is optional, however furnishing the
information is required in order to obtain and/or retain benefits. According to the Paperwork Reduction Act of 1995, an agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 1240-0042. The time required to complete this information collection is estimated to average 15
minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Longshore and Harbor Worker's
Compensation, Room C4319, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

DO NOT SEND COMPLETED FORMS TO THIS OFFICE.
Form LS-208
Rev. xxxxxxxxxxxxx