Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act

Administration of the Longshore and Harbor Workers' Compensation Act

OMB: 1240-0014

IC ID: 43808

Documents and Forms
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Document Type
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Other-Recordkeeping
Other-Recordkeeping
Instruction
Instruction
Instruction
Instruction
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
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IC Document
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Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 702.285 20 CFR 702.242 20 CFR 702.174 20 CFR 702.221 20 CFR 702.162 20 CFR 702.111 20 CFR 702.321 20 CFR 702.175 20 CFR 702.202 20 CFR 703.310 20 CFR 702.201

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form LS-201 Notice of Employee's Injury or Death ls-201 (1).pdf http://www.dol.gov/owcp/dlhwc/ls-201.pdf Yes No Fillable Fileable Signable
Form LS-513 Report of Payments LS-513(1).pdf http://www.dol.gov/owcp/dlhwc/LS-513.pdf Yes Yes Fillable Fileable
Form LS-267 Claimant's Statement ls-267(1).pdf http://www.dol.gov/owcp/dlhwc/LS-267.pdf Yes Yes Fillable Fileable Signable
Form LS-203 Employee's Claim for Compensation ls-203(1).pdf http://www.dol.gov/owcp/dlhwc/ls-203.pdf Yes Yes Fillable Fileable Signable
Form LS-262 Claim for Death Benefits ls-262(1).pdf http://www.dol.gov/owcp/dlhwc/ls-262.pdf Yes Yes Fillable Fileable Signable
Other-Recordkeeping ESA 100.doc No   Paper Only
Form LS-271 Application for Self-Insurance ls-271(1).pdf http://www.dol.gov/owcp/dlhwc/LS-271.pdf Yes Yes Fillable Fileable
Form LS-204 Attending Physician's Supplementary Report ls-204(1).pdf http://www.dol.gov/owcp/dlhwc/ls-204.pdf Yes Yes Fillable Printable
Form LS-274 Report of Injury Experience of Insurance Carrier or Self-Insured Employer ls-274(1).pdf http://www.dol.gov/owcp/dlhwc/LS-274.pdf Yes No Fillable Printable
Form LS-200 Report of Earnings ls-200(1).pdf http://www.dol.gov/owcp/dlhwc/ls-200.pdf Yes Yes Fillable Fileable Signable
Instruction LS-272instructions1.pdf https://www.dol.gov/owcp/dlhwc/LS-272instructions.pdf Yes No Paper Only
Form LS-272 Application to write Longshore Insurance ls-272(1).pdf https://www.dol.gov/owcp/dlhwc/LS-272.pdf Yes Yes Fillable Fileable Signable
Instruction LS-271instructions(1).pdf https://www.dol.gov/owcp/dlhwc/LS-271instructions.pdf Yes No Paper Only

Income Security General Retirement and Disability

DOL/OWCP-3  67 FR 16886

53,842 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 53,842 0 0 0 0 53,842
Annual IC Time Burden (Hours) 20,752 0 0 0 0 20,752
Annual IC Cost Burden (Dollars) 786 0 -8,739 0 0 9,525

Title Document Date Uploaded
DLHWC SEA Portal DLHWC Seaportal.pdf 09/24/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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