Agency:

OWCP-DLHWC

Title:

DLHWC (Longshore) LS-201, Notice of Employee's Injury or Death

Form Description:

DLHWC (Longshore) LS-201, Notice of Employee's Injury or Death: The employer furnishes this form to an injured worker. The employee or duly appointed representative completes the form to provide written notice of injury or death to the employer. The information from the form is used to assist in determining entitlement to workers' compensation benefits. This form is not to be used in lieu of a formal claim for compensation benefits, or form LS-203.

OMB Control Number:

1215-0160

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