Form LS-570 Carrier's Report of Issuance of Policy

CARRIER’S REPORT OF
ISSUANCE OF POLICY

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U.S. Department of Labor

Office of Workers' Compensation Programs
Division of Longshore and Harbor Workers' Compensation

Form LS-570 is used by authorized carriers to report the policy of insurance issued for each insured employer. This form is to be
sent to the Deputy Commissioner in the compensation district indicated by the employer’s address. Section 32 (a) of the
Longshore and Harbor Workers' Compensation Act (33 USC 932(a)), and its extensions requires every employer to secure the
payment of compensation under this Act either (1) by insuring and keeping insured the payment of such compensation with any
insurance company authorized by the Secretary, to insure payment of compensation under this Act; or (2) receiving an
authorization from the Secretary to pay such compensation directly.
1. Date

2. Jurisdiction (Act or Extension)
Longshore and Harbor Workers’ Compensation Act

OMB No.: 1240-0004
Expiration Date: 07/31/2022

Defense Base Act

Outer Continental Shelf Lands Act
Non-Appropriated Funds Instrumentalities Act
Carrier Details
3. Insurance Carrier Name

4. Carrier Federal Employer Identification Number (FEIN)

Policy Details
5. Policy Number

6. Effective Date

7. Expiration Date

8. Prior Policy Number

9. Governing Class

10. Total Payroll

Employer Details
11. Employer Name and Address

12. Employer FEIN

13. Employer Phone Number

14. Authorized Signature

Title

Send completed form to USDOL/OWCP/DLHWC, Room S-3229, 200 Constitution Avenue, N.W., Washington, D.C. 20210
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 5 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. (20 CFR 703.116). 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, NW, Room S-3229, Washington, D.C. 20210, and reference the OMB Control Number.

Form LS-570
January 2010