Carrier's Report of Issuance of Policy

OMB 1240-0004

OMB 1240-0004

The Carrier's Report of Issuance of Policy (Form LS-570) is used by authorized insurance 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 LHWCA (33 USC 932(a)), requires every employer to secure 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.

The latest form for Carrier's Report of Issuance of Policy expires 2022-07-31 and can be found here.


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