Data Element Crosswalk for LS-208

1240-0041 Data Elements Table updated 1.2018.docx

Notice of Payments

Data Element Crosswalk for LS-208

OMB: 1240-0041

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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

  1. 5. Date of accident or first illness

  1. 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



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorJordan, Cheryl B - OWCP
File Modified0000-00-00
File Created2021-01-21

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