Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form LS-275 (IC) Agreement and Undertaking (Insurance Carrier)	Form	Modified	Available
Form LS-275 (SI) Agreement and Undertaking (Self-Insured Employer)	Form	Modified	Available
Form LS-276 Application for Security Deposit Determination	Form and Instruction	Modified	Available
1240-0005 Supporting Statement 2026.docx	Supporting Statement A	Uploaded 2026-08-06	Available
Public Comment by Larry Dembrun.pdf	Public Comments	Uploaded 2026-07-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13942	Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions	Form	Modified	Agreement and Undertaking (Insurance Carrier)
13942	Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions	Form	Modified	Agreement and Undertaking (Self-Insured Employer)
13942	Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions	Form and Instruction	Modified	Application for Security Deposit Determination

ICR Details

OMB Control No: 1240-0005	ICR Reference No: 202607-1240-001
Status: Received in OIRA	Previous ICR Reference No: 202304-1240-005
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/19/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2026
Responses	728	705
Time Burden (Hours)	911	881
Cost Burden (Dollars)	728	409

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Abstract: OWCP Forms LS-275-IC, LS-275-SI, and LS-276 cover the submission of information by insurance carriers and self-insured employers regarding their ability to meet their financial obligations under the Longshore Act and its extensions.

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Authorizing Statute(s): US Code: 33 USC 932 Name of Law: Longshore and Harbor Workers' Compensation Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 11087	03/06/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 53652	08/19/2026
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions	LS-275 (IC), LS-275 (SI), LS-276	Application for Security Deposit Determination ,   Agreement and Undertaking (Self-Insured Employer) ,   Agreement and Undertaking (Insurance Carrier)

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	728	705	0	0	23	0
Annual Time Burden (Hours)	911	881	0	0	30	0
Annual Cost Burden (Dollars)	728	409	0	0	319	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There is an increase of number of hours from the previously-established burden hours due to a slight increase in the number of authorized insurance carriers from the last submission. Burden hours have increased from 881 to 911 due to an increase in responses and respondents which increased both from 705 to 728.

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Annual Cost to Federal Government: $23,680

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/19/2026

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