OMB control number

Administration of the Longshore and Harbor Workers' Compensation Act

OMB 1240-0014 · DOL/OWCP.

OMB 1240-0014

The regulations and forms cover the submission of information relating to the processing of claims for benefits under the Longshore Act and extensions.

The latest form for Administration of the Longshore and Harbor Workers' Compensation Act expires 2026-11-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form LS-513 Report of Payments Form and Instruction
Form LS-271 Application for Self-Insurance Form and Instruction
Form LS-274 Report of Injury Experience of Insurance Carrier or Self-Insured Employer Form and Instruction
Form LS-272 Application to write Longshore Insurance Form and Instruction
Form LS-267 Claimant's Statement Form and Instruction
Form LS-262 Claim for Death Benefits Form and Instruction
Form LS-204 Attending Physician's Supplementary Report Form and Instruction
Form LS-203 Employee's Claim for Compensation Form and Instruction
Form LS-201 Notice of Employee's Injury or Death Form and Instruction
Form LS-200 Report of Earnings Form and Instruction
Justification for No material change to 1240-0014 (LS-201 and LS-203) 2025.docx Justification for No Material/Nonsubstantive Change
Supporting Statement for 1240-0014 September 2023 CLEAN.docx Supporting Statement A
Supporting Statement for 1240-0014 September 2023 CLEAN.docx Supporting Statement A
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act Form and Instruction
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act Form and Instruction
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act Form and Instruction
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act Form and Instruction
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act Form and Instruction
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act Form and Instruction
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act Form and Instruction
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act Form and Instruction
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act Form and Instruction
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act Form and Instruction
Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act Other-Recordkeeping

All Historical Document Collections

202502-1240-005	No material or nonsubstantive change to a currently approved collection	2025-02-19
202307-1240-001 Approved without change	Revision of a currently approved collection	2023-09-25
202012-1240-001	No material or nonsubstantive change to a currently approved collection	2020-12-15
202001-1240-002 Approved without change	Revision of a currently approved collection	2020-05-27
201803-1240-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2018-04-24
201612-1240-009 Approved without change	Extension without change of a currently approved collection	2017-01-31
201509-1240-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2015-10-19
201506-1240-005 Approved without change	Revision of a currently approved collection	2015-06-05
201412-1240-006 Preapproved	No material or nonsubstantive change to a currently approved collection	2015-03-12
201409-1240-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2014-09-30
201407-1240-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2014-07-03
201309-1240-005 Approved without change	Revision of a currently approved collection	2013-12-27
201202-1240-003 Approved without change	Revision of a currently approved collection	2012-06-29
201003-1240-014 Approved without change	Extension without change of a currently approved collection	2010-03-12