OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

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

IC 43808 under ICR 202502-1240-005 · OMB 1240-0014.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form LS-200
Report of Earnings Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form and Instruction
Form LS-201
Notice of Employee's Injury or Death Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form and Instruction
Form LS-203
Employee's Claim for Compensation Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form and Instruction
Form LS-204
Attending Physician's Supplementary Report Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form and Instruction
Form LS-262
Claim for Death Benefits Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form and Instruction
Form LS-267
Claimant's Statement Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form and Instruction
Form LS-272
Application to write Longshore Insurance Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form and Instruction
Form LS-274
Report of Injury Experience of Insurance Carrier or Self-Insured Employer Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form and Instruction
Form LS-271
Application for Self-Insurance Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form and Instruction
Form LS-513
Report of Payments Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act		 Form and Instruction
ESA 100.doc Other-Recordkeeping
ESA 100.doc Other-Recordkeeping
LS-272instructions1.pdf
www.dol.gov/owcp/dlhwc/LS-272instructions.pdf 		Instruction
LS-272instructions1.pdf
www.dol.gov/owcp/dlhwc/LS-272instructions.pdf 		Instruction
LS-271instructions(1).pdf
www.dol.gov/owcp/dlhwc/LS-271instructions.pdf 		Instruction
LS-271instructions(1).pdf
www.dol.gov/owcp/dlhwc/LS-271instructions.pdf 		Instruction
LS-200 Report of Earnings
ls-200.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-200.pdf 		Form and Instruction
LS-200 Report of Earnings
ls-200.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-200.pdf 		Form and Instruction
LS-201 Notice of Employee's Injury or Death
ls-201 post-1-20-25 updated version.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-201.pdf 		Form and Instruction
LS-201 Notice of Employee's Injury or Death
ls-201 post-1-20-25 updated version.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-201.pdf 		Form and Instruction
LS-203 Employee's Claim for Compensation
ls-203 post-1-20-25 updated version.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-203.pdf 		Form and Instruction
LS-203 Employee's Claim for Compensation
ls-203 post-1-20-25 updated version.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-203.pdf 		Form and Instruction
LS-204 Attending Physician's Supplementary Report
ls-204.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-204.pdf 		Form and Instruction
LS-204 Attending Physician's Supplementary Report
ls-204.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-204.pdf 		Form and Instruction
LS-262 Claim for Death Benefits
ls-262.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-262.pdf 		Form and Instruction
LS-262 Claim for Death Benefits
ls-262.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-262.pdf 		Form and Instruction
LS-267 Claimant's Statement
LS-267.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-267.pdf 		Form and Instruction
LS-267 Claimant's Statement
LS-267.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-267.pdf 		Form and Instruction
LS-272 Application to write Longshore Insurance
LS-272.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-272.pdf 		Form and Instruction
LS-272 Application to write Longshore Insurance
LS-272.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-272.pdf 		Form and Instruction
LS-274 Report of Injury Experience of Insurance Carrier or Self
LS-274.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-274.pdf 		Form and Instruction
LS-274 Report of Injury Experience of Insurance Carrier or Self
LS-274.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-274.pdf 		Form and Instruction
LS-271 Application for Self-Insurance
LS-271.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-271.pdf 		Form and Instruction
LS-271 Application for Self-Insurance
LS-271.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-271.pdf 		Form and Instruction
LS-513 Report of Payments
LS-513.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-513.pdf 		Form and Instruction
LS-513 Report of Payments
LS-513.pdf
www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-513.pdf 		Form and Instruction
DLHWC Seaportal.pdf
DLHWC SEA Portal		IC Document
DLHWC Seaportal.pdf
DLHWC SEA Portal		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Recordkeeping No   Paper Only
Instruction https://www.dol.gov/owcp/dlhwc/LS-272instructions.pdf Yes No Paper Only
Instruction https://www.dol.gov/owcp/dlhwc/LS-271instructions.pdf Yes No Paper Only
Form and Instruction LS-200 https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-200.pdf Yes Yes Fillable Fileable
Form and Instruction LS-201 https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-201.pdf Yes Yes Fillable Fileable
Form and Instruction LS-203 https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-203.pdf Yes Yes Fillable Fileable
Form and Instruction LS-204 https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-204.pdf Yes Yes Fillable Fileable
Form and Instruction LS-262 https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-262.pdf Yes Yes Fillable Fileable
Form and Instruction LS-267 https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-267.pdf Yes Yes Fillable Fileable
Form and Instruction LS-272 https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-272.pdf Yes Yes Fillable Fileable
Form and Instruction LS-274 https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-274.pdf Yes Yes Fillable Fileable
Form and Instruction LS-271 https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-271.pdf Yes Yes Fillable Fileable
Form and Instruction LS-513 https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-513.pdf Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  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 76,417 0 0 0 0 76,417
Annual IC Time Burden (Hours) 21,155 0 0 0 0 21,155
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
DLHWC SEA Portal 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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