Form ls-266 dev ls-266 dev Application for Continuation of Death Benefit for Studen

Application for Continuation of Death
Benefit for Student (under the Longshore

and Harbor Workers' Compensation Act as extended)

U.S. Department of Labor
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Office of Workers' Compensation Programs
OMB No. 1240-0026
Expires: 03/31/2017
FOR OFFICE USE
OWCP No.

INSTRUCTIONS: Submit this form for the dependent on whose behalf this application is filed to the Office of Workers'
Compensation Programs (OWCP), Division of Longshore and Harbor Workers' Compensation (DLHWC) Central Mail
Room, 400 West Bay Street, Suite 63A, Box 28, Jacksonville, FL 32202.
Have an official of the institution being attended by the dependent complete items in Part B. See reverse for requirement
for qualifying as a student under the act. This form is authorized by law (33 U. S. C. 939(a)) and is required to obtain a
benefit. Failure to submit this form may result in delay in receiving continuing death benefits for the student. See reverse
for "Privacy Act" statement.
PART A. (items 1 thru 12) To be completed by the Individual to whom benefits for a
dependent child, grandchild, brother or sister are being paid
1. Name of deceased upon whom dependency was based
First Name
M.I.
Last Name
2. Name of dependent
First Name

M.I.

Last Name

3. Is dependent now pursuing a full-time course of study or training?
Yes - complete items 4, 5, and 6

No - Skip to item 7
4. Name and address of
educational institution attended

5. Date attendance at this institution began
(mm/dd/yyyy)

Carrier's No.

Mark act under which benefit is being paid
A

Longshore and Harbor Workers' Compensation Act

B

Defense Base Act

C

Nonappropriated Fund Instrumentalities Act

D

Outer Continental Shelf Lands Act

E

District of Columbia Compensation Act

name:
line 1:

city:

line 2:

state:

country:
zip:

6. Does dependent expect to complete education or training at this institution?
month
year
Yes - enter month, year
No

Don't know

7. Does dependent intend to go to school next year?

No
8. Name and address of school
where accepted or intends to enroll

Yes - complete item 8

Don't know

name:
line 1:

city:

line 2:

state:

country:
zip:

9. I hereby certify that the information given by me on and in connection with this questionnaire is true and correct to the best
of my knowledge and belief.

10. Signature of parent or guardian (Person to whom benefits are
being paid)
10a. Print name of parent or guardian

Phone #

12. Date

11. Address No., street, city, state, ZIP Code)
line 1:

city:

line 2:

st:

(mm/dd/yyyy)
zip:

country:

PART B. To be completed by an official of the institution named in item 4
13. I have read the foregoing and those facts which I am normally able to verify are correct. Please note below any exceptions

14. If your institution is neither a high school, college, or university, please state the agency by which it is accredited or licensed.

15. Signature and title (type and sign)

15a. Name, address and phone number of educational institution
name:

16. Date signed
(mm/dd/yyyy)

address:
Phone:
Form LS-266
Rev. March 2014

REQUIREMENTS FOR QUALIFYING AS A STUDENT FOR
CONTINUING BENEFITS AFTER AGE 18
To qualify for a continuing death benefit after reaching the age of 18 years, under the Longshore and Harbor Workers'
Compensation Act or one of the Act's extensions, a child, grandchild, brother, or sister must be either (1) incapable of
self-support by reason of mental or physical disability, or (2) be a student, regularly pursuing a full-time course of study or
training at an institution which is1. A school, college, or university operated or directly supported by the United
States, or by any State or local government or political sub-division thereof,
2. A school, college, or university which has been accredited by a State
recognized or nationally recognized accrediting agency or body,
3. A school, college, or university not so accredited but whose credits are
accepted, on transfer, by not less than three institutions which are so
accredited, for credit on the same basis as if transferred from an institution so
accredited, or
4. An additional type of educational or training institution as defined by the
Secretary of Labor.
Compensation may be paid so long as a dependent continues to pursue a full-time course of study at a recognized institution.
In no event may compensation be paid beyond the end of the semester or enrollment period after the dependent reaches the
age of 23 or has completed four years of education. A child shall not be deemed to have ceased to be a student during any
period between school years if the period does not exceed five months and if he or she shows to the satisfaction of the
Secretary of Labor that he has a bona fide intention of continuing to pursue a full-time course of education or training during
the semester or other enrollment period immediately following the period or during periods of reasonable duration during
which, in the judgment of the Secretary, the dependent is prevented by factors beyond his or her control.
A child or dependent shall not be deemed to be a student under this Act during a period of service in the Armed Forces of the
United States.

PRIVACY ACT OF 1974 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 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 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.
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
30 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. 939(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, N.W., Room C-4319, Washington, D.C. 20210, and reference the OMB Control
Number.
DO NOT SEND COMPLETED FORMS TO THIS OFFICE.