| FORM
NO. |
EXHIBIT NO. |
TITLE |
DISTRIBUTION |
PM
REFERENCE |
| LS-1 |
1 |
Request for Examination
and/or Treatment |
|
5-200.3 |
| LS-3 |
2 |
District Office
Statistical Report |
Orig: NO |
9-200 |
| LS-3s |
3 |
Supplemental
Statistical Report and Definitions for Form LS-3s |
Orig: NO |
9-300 |
| OWCP-14 |
4 |
Referral to OWCP
Rehabilitation |
Distribute Copies As Shown on
Form |
3-301.3g |
| LS-18 |
5 |
Pre-Hearing
Statement |
To All Parties |
4-200.10,
4-600.3a |
| LS-19 |
6 |
Certificate of Filing
and Service (for use with ALJ orders) |
Orig: Case File
cc: All Parties
|
4-600.8b |
| LS-19a |
7 |
Certificate of Filing
and Service (for use with DD orders) |
Orig: Case File
cc: All
Parties |
4-200.9c,
4-600.8b |
| LS-20 |
8 |
Notification of ALJ
Decision |
Orig: All Parties
cc: Case File
|
4-600.8c |
| LS-21 |
9 |
Guidance for Completion
of LS-18 |
To All Parties |
4-600.3a
|
| LS-33 |
10 |
Approval of Compromise
of Third Person Cause of Action |
Orig: Claimant
cc: Case
File |
3-600.2 |
| CA-58 |
11 |
Case File
Transfer |
Orig: Case File
cc: With Case
File Releasing Office |
1-501.4a |
| CA-67 |
12 |
Case File Transmittal
Sheet |
Orig: Receiving Office
cc:
Releasing Office Case File |
1-501.4c |
| LS-141 |
13 |
Notice of Informal
Conference |
To All Parties |
4-200.5a(2),
6-201.5b |
| LS-200 |
14 |
Report of
Earning |
Disability Benefit
Recipients |
6-300.2 |
| LS-201 |
15 |
Notice of Employee's
Injury or Death |
|
15
1-400.3,
2-201.4a
|
| LS-202 |
16 |
Employer's First Report
of Injury or or Occupational Disease |
|
16
1-400.3,
2-201.2,
3-301.3f(1),
8-302.3a |
| LS-203 |
17 |
Employee's Claim for
Compensation |
|
1-400.3,
2-201.4a,
4-403.5c
|
| LS-204 |
18 |
Attending Physician's
Supplementary Report |
|
1-400.3,
5-300.4
|
| LS-206 |
19 |
Payment of Compensation
Without Award |
|
1-400.3,
2-201.2b,
3-301.3b,
3-301.5
|
| LS-207 |
20 |
Notice of Controversion
of Right to Compensation |
|
2-201.3d,
3-301.3d
|
| LS-208 |
21 |
Notice of Final Payment
or Suspension of Compensation Payments |
|
1-400.3,
2-201.3b,
3-301.3f(2),
3-301.5b,
3-301.10b
|
| LS-209 |
22 |
Request for Employee's
Reply to Employer's Objections |
Orig: Claimant
cc: Claimant's
Representative EC,
Case File |
2-201.3d,
3-301.3d |
| LS-210 |
23 |
Employer's
Supplementary Report of Accident or Occupational Illness |
|
2-201.2h
|
| LS-215a |
24 |
Notice to Employer and
Insurance Carrier That Claim Has Been Filed |
Orig: EC
cc: Claimant,
Claimant's Representative,
Case File |
2-201.4
|
| LS-216 |
25 |
Request for Additional
Reports |
Orig: EC
cc: Case
File |
3-301.3e(3),
5-300.3 |
| LS-222 |
26 |
Carrier's or Self
Insurer's Report on Rehabilitation to Deputy Commissioner |
Distribute Copies As Shown on
Form |
3-301.3g
|
| LS-226a |
27 |
Subpoena Duces
Tecum |
To Any Party |
4-400.11 |
| LS-239 |
28 |
Compensation
Certificate |
Orig: To Employer
cc: DO
Insurance Section |
7-500.5 |
| LS-240 |
29 |
Compensation
Certificate for Self-Insured Employers |
Orig: To Self-Insured Employer cc:
DO Insurance Section |
7-500.5
|
| LS-241 |
30 |
Notice to
Employees |
Orig: To
Employer |
|
| LS-242 |
31 |
Notice to Employees
(for Self-Insured Employers) |
Orig: To
Employer |
|
| LS-262 |
32 |
Claim for Death
Benefits |
|
1-400.3,
2-202.3
|
| LS-265
|
33 |
Certification of
Funeral Expenses |
|
2-202.3,
3-302.8
|
| LS-266 |
34 |
Application for
Continuation of Death benefit for Student |
|
2-202.3,
3-302.5 |
| LS-267 |
35 |
Claimant's Statement
|
Death Benefit
Recipients |
6-300.2 |
| LS-274 |
36 |
Report of Injury
Experience |
|
7-400.8a |
| LS-280 |
37 |
Memorandum of Informal
Conference |
Orig: Case File
cc: All
Interested Participants |
4-200.8,
4-200.10b |
| LS-403 |
38 |
Employee's Right to
File Claim for Disability Compensation |
Orig: To Claimant
cc: Case
File |
2-201.2f,
3-301.12b |
| LS-426 |
39 |
Request to Employee for
Wage Earnings Information |
Orig: To Claimant
cc: EC, Case
File |
2-201.3b,
3-301.3b |
| LS-504 |
40 |
Letter to Employee
Explaining Rights |
Orig: To Claimant
cc: Case
File |
1-400.3d,
3-301.12c |
| LS-512 |
41 |
Request to Employer for
Form LS-202 |
Orig: To Employer
cc: Case
File |
8-302.5d
|
| LS-521 |
42 |
Annual Adjustment of
Award |
Orig: EC
cc: Claimant,
Case
File |
3-202.5b |
| LS-526 |
43 |
Letter to Employee
Explaining Need for Employer's Approval of Third Party
Settlement |
Orig: To Claimant
cc: EC,
Claimant's Representative,
Case File |
3-600.2
|
| LS-535 |
44 |
Notice to Guardian of
Provision for Benefit Continuation |
Orig: To Parent or Guardian cc: EC,
Case File |
3-302.5a
|
| LS-536 |
45 |
Notice to Guardian of
Requirement to Complete Form LS-266 |
Orig: To Parent or Guardian cc: EC,
Case File |
3-302.5b |
| LS-537 |
46 |
Notice of Recommended
Change in Compensation Based on Higher AWW |
Orig: EC
cc: Claimant, Case
File |
3-201.8a,
3-301.3b |
| LS-541 |
47 |
Recommendation to EC to
Accept Continuation of Death Benefits |
Orig: EC
cc: Parent or
Guardian,
Case File |
3-302.5c |
| LS-548 |
48 |
Letter Explaining EC's
Responsibility to File Timely LS-202 |
Orig: To Employer
cc: Case
File |
8-302.4b
|
| LS-551 |
49 |
Notice Assessing
Penalty for Late Filing of Form LS-202 |
Orig: To Employer
cc: Case File
|
8.302.5d |
| LS-552 |
50 |
Notice to EC of Penalty
for Late Filing of Form LS-208 |
Orig: To
Employer |
8-301.6d
|
| LS-557 |
51 |
Notice to Employee of
Compensation Rate Under LHWCA |
Orig: To Claimant
cc: Case
File |
2-201.3b |
| LS-570 |
52 |
Card Report of
Insurance |
|
7-300.8,
7-500.2 |
| |
53
(Reserved) |
|
|
|
| AR-10 |
54 |
Corrective Action
Report |
Orig: To Office of Management,
Administration, and Planning |
9-500.3c,
9-600.4 |
| |
55
(Reserved) |
|
|
|
| DL
1-301 |
56 |
Cash Receipts
Register |
Orig: Remains in
DO |
1-200.9e,
8-302.8
|
| DL
1-303 |
57 |
Cash Transfer Receipt
|
Orig: Remains in DO
cc: To NO,
or Regional Office |
1-200.9f,
8-301.8,
8-400.6
|
