LS-271instructions(1)

REQUIREMENTS FOR AUTHORIZATION TO BE SELF‐INSURED UNDER THE 
LONGSHORE AND HARBOR WORKERS’ COMPENSATION ACT  
AND/OR EXTENSIONS 

The following information and instructions pertain to the requirements for authorization to 
become self‐insured under the Longshore and Harbor Workers’ Compensation Act and 
extentions, Defense Base Act, Nonappropriated Fund Instrumentalities Act and Outer 
Continental Shelf Lands Act. 

ATTACHMENT: 

Form LS‐271, Application for Self‐Insurance 

INFORMATION AND MATERIAL WHICH MUST BE SUBMITTED: 

1) Completed Form LS‐271, Application for Self‐Insurance.  A separate application must 
be completed under each Act for each separately incorporated subsidiary.  A parent 
company must guarantee the obligations of each subsidiary.  The guaranty must be 
submitted on parent company letterhead.  

2) Certified audited financial statements for the most recent three years. 

3) Loss information under the Act for the most recent five years, showing loss 
information for each year, including total incurred, paid and outstanding losses. 

4) Information pertaining to specific excess insurance.  The net retention and 
maximum limit should be shown, and a specimen copy of the policy should be 
included.   

5) Statement showing amount of annual payroll under the Act by insurance 
classification code. 

6) Statement pertaining to the proposed administration of claims.  If claims are to be 
self‐administered, a statement should be submitted showing the qualifications of 
those individuals who will process claims.  If a self‐insurance service organization is 
to be used, a profile of the organization should be submitted, showing the 
experience of claims handling personnel managing cases under the Act. 

7) Employer Identification Number (EIN) for each applicant company.  This can be 
furnished in item 2 of the application.   

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8) A  certification by a corporate officer on company letterhead stating that the
applicant company will perform the following:
a. Comply with all statutory and regulatory obligations, including meeting  timeliness
for paying benefits and reporting information [Section 14(a) – (i)];
b. Utilize the informal dispute resolution mechanisms in good faith by bringing only
issues that are ready for resolution (i.e. all documentation is available) and sending
representatives who are both prepared to and have authority to resolve issues;
c. Participate and cooperate with all efforts by professional and trade associations to
self‐police industry compliance;
d. Monitor and be held responsible for the performance in numbers 1‐2 above of their
Third Party Administrator (TPA) or other claims handlers; and
e. Respond to all penalty assessments in a timely manner.
There is no filing fee or other cost associated with filing an application for self‐insurance 
authorization.  You should allow about 30 to 60 days for processing upon receipt of a 
completed application.   
If a third party is filing on behalf of a client company then the application should contain the 
name of the responsible person and the address of the client company to whom notification of 
the decision should be sent.  If all correspondence is to be sent to the third party, the 
application should so indicate.    
The completed application form and all related material should be submitted to:  
U.S. Department of Labor  
OWCP/DLHWC, Room S-3229 
200 Constitution Avenue, N.W. 
Washington, D.C.   20210 
Questions relating to self‐insurance should be addressed to the Longshore Insurance Branch 
at the same address.  The telephone number is (202) 354-9620. 
Director Division 
of Longshore and Harbor 
Workers’ Compensation  
(2/12) 

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PLEASE

TYPE

THIS

STATEMENT

ON

PARENT

COMPANY

LETTERHEAD

PARENT COMPANY GUARANTY
Guaranty made on (date) by (parent company) of (address) as
guarantor of all obligations incurred by (subsidiary company) of
(address) under the Longshore and Harbor Workers' Compensation
Act and/or its extensions, the Outer Continental Shelf Lands Act;
the Defense Base Act and the Nonappropriated Fund
Instrumentalities Act.
In consideration of the granting of self-insurance authority
under the Longshore and Harbor Workers' Compensation Act and/or
its extensions, the Outer Continental Shelf Lands Act; the
Defense Base Act and the Nonappropriated Fund Instrumentalities
Act to (subsidiary company), (parent company) unequivocally
guarantees the payment of all obligations incurred by (subsidiary
company) under the Longshore and Harbor Workers' Compensation Act
and/or its extensions, the Outer Continental Shelf Lands Act; the
Defense Base Act and the Nonappropriated Fund Instrumentalities
Act. This guaranty is absolute and unconditional and continuous
except as specifically provided below.
(Parent company) may revoke this guaranty, effective on the last
day of any annual period of authorization or reauthorization by
the Secretary of Labor or designee of (subsidiary company) to act
as a self-insurer under the Longshore and Harbor Workers'
Compensation Act and/or its extensions, by giving notice to the
Division of Longshore and Harbor Workers' Compensation by
registered mail not less than 60 days prior to the effective date
of such revocation; provided, that any such revocation shall not
affect (parent company's) continuing obligation to guarantee all
obligations of (subsidiary company) whenever accruing, for which
(subsidiary company) is liable under the Longshore and Harbor
Workers' Compensation Act and/or its extensions, the Outer
Continental Shelf Lands Act; the Defense Base Act and the
Nonappropriated Fund Instrumentalities Act, on the basis of its
conduct of employment during the period this guaranty was in
effect.
I, being the duly elected and acting Secretary of (parent
company) do hereby certify that the foregoing was duly adopted by
the Board of Directors of (parent company) at a meeting thereof
duly called and held on (date), at which a quorum was present and
acting throughout, and that said guaranty is in full force and
effect.
___________________
Corporate Seal

_______________________
Signature
_______________________
Typed Name and Title

___________________
Notary Seal

_______________________
Date