Notice of Payments

OMB 1240-0041

Report is used by insurance carriers and self-insured employers to report the payment of benefits under the Longshore and Harbors Workers Compensation Act.

The latest form for Notice of Payments expires 2021-08-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form LS-208 Notice of Payments Form and Instruction
30-day FRN (1240-0041) published.pdf Supplementary Document
1240-0041 Supporting Statement 6-29-21 clean.docx Supplementary Document
1240-0041 Supporting Statement 6-29-21 clean.docx Supporting Statement A
914(c).docx Supplementary Document
914(b).docx Supplementary Document
20CFR702_702_236 - Penalty for failure to report termination of payments.htm Supplementary Document
20CFR702_702_235 - Report by employer of final payment of compensation.htm Supplementary Document
33 USC 914(g).doc Supplementary Document
Notice of Payments Form and Instruction

All Historical Document Collections

202105-1240-001 Approved with change	Revision of a currently approved collection	2021-07-01
202008-1240-054	No material or nonsubstantive change to a currently approved collection	2020-12-15
201803-1240-001 Approved without change	Extension without change of a currently approved collection	2018-06-01
201712-1240-001 Approved with change	No material or nonsubstantive change to a currently approved collection	2018-01-09
201611-1240-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-11-25
201411-1240-003 Approved without change	Revision of a currently approved collection	2015-02-27
201409-1240-009 Approved without change	No material or nonsubstantive change to a currently approved collection	2014-09-30
201110-1240-002 Approved without change	Revision of a currently approved collection	2012-01-13
201003-1240-041 Approved without change	Extension without change of a currently approved collection	2010-03-12