Data Element Crosswalk for LS-208

Data Element Table – Comparison of Proposed LS-208 and Current LS-206 and LS-208

Proposed LS-208 – Notice of Payments	Current LS-206 – Payment of Compensation without Award	Current LS-208 – Notice of Final Payment or Suspension of Compensation Payments
1. Date of Accident/Illness	5. Date of accident or first illness	6. Date of Injury
2. Carrier’s No.	2. Carrier’s No.	2. Carrier’s No.
3. OWCP No.	1. OWCP No.	1. OWCP No.
4. Name of Injured Worker and Claimant If other than worker	3. Name of Injured Person. 7. Name of injured, or dependents of injured, to whom compensation will be paid	3. Name and Address of Employee or other beneficiary
5. Claimant’s Address	4. Address of injured person	5. Address of employer
6. Compensation Disability Type	9. Type of compensation paid, payment begin date, is the employer continuing to pay injured person’s salary, are these payments being made in lieu of compensation payments
7. Date employee first lost time	6. Date disability began
8. Average weekly wage	8. Average weekly wage
9. Payment begin date	9. Type of compensation paid, payment begin date, is the employer continuing to pay injured person’s salary, are these payments being made in lieu of compensation payments
10. Employer continuing to pay the injured person’s salary? If so, are the salary continuation payments made in lieu of compensation payments?		10. Was compensation paid at the maximum rate
11. Date first check issued	10. Date of first payment	7. Date first check issued
12. Type of notice: initial, interim, final	Form utilized for initial payment	Form utilized for interim and final payment
13. State reason for interim or final payment notice		11. State reason or reasons for termination or suspension of payments
14. Date last payment made		12. Date last payment made
15. Enter all payments made on account of disability (Table)		14. Enter all payments made on account of disability (Table)
16. Enter other payments (Table)		16. Enter other payments (Table)
17. Employer name, employer address	12. Name and address of employer	4. Name of employer 5. Address of employer
18. Name of insurance carrier or self-insured employer and administrator, address and phone number of person whose name is shown in Box 18	13. Name and address of insurance carrier and/or claim administrator	17. Name of insurance
19. Signature of person authorized to sign for employer or carrier	14. Authorized signature	18. Signature of person authorized to sign for employer or carrier
20. Print name of authorized person	15. Type or print title and name of person whose signature appears in item 14	19. Name and title of person whose signature appears in Box 18
21. Date of notice	16. Date signed	13. Date of this notice