Skip to page content
Office of Workers' Compensation Programs
Bookmark and Share

Division of Longshore and Harbor Workers' Compensation (DLHWC)

DLHWC Longshore Forms

On This Page

OWCP's Division of Longshore and Harbor Workers' Compensation (DLHWC/Longshore) has made the following forms available online. Some of these forms are available in Adobe PDF format. In order to view and/or print PDF documents you must have a PDF viewer. It is highly recommended that you have the most current version of Adobe Reader available on your workstation. When printing these forms, Please use the PRINT BUTTON on the form itself.  It is located in the TOP LEFT corner of the form. DO NOT use your browser's print icon on the browser toolbar.

Form Number

OWCP's Form Title/Description

LS-1

Request for Examination and/or Treatment

LS-18

Pre-Hearing Statement

LS-33

Approval of Compromise of Third Person Cause of Action

LS-200

Report of Earnings

LS-201

Notice of Employee's Injury or Death

LS-202

Employer's First Report of Injury or Occupational Illness

LS-203

Employee's Claim for Compensation

LS-204

Attending Physician's Supplementary Report

LS-206

Payment of Compensation Without Award

LS-207

Notice of Controversion of Right to Compensation

LS-208

Notice of Final Payment or Suspension of Compensation Payments

LS-210

Employer's Supplementary Report of Accident or Occupational Illness

LS-241 / LS-242

Notice to Employees (This form is provided by the Insurance Carrier when the policy is issued. Employers should request from their carrier. Carriers and self-insurers should request from their corporate compliance department.)

LS-262

Claim for Death Benefits

LS-265

Certification of Funeral Expenses

LS-266

Application for Continuation of Death Benefit for Student

LS-267

Claimant's Statement

LS-271

Application for Self-Insurance instructions

LS-272

Application to write Longshore Insurance (Carriers)

LS-274

Report of Injury Experience of Insurance Carrier or Self-Insured Employer


LS-275ic NEW

Agreement and Undertaking (Insurance Carrier)


LS-275si NEW

Agreement and Undertaking (Self-Insured Employer)

LS-276

Application for Security Deposit Determination. State Guarantee Fund Longshore Security Factor Chart

LS-426

Request for Earnings Information

LS-513

Report of Payments.

LS-570

Carrier's Report of Issuance of Policy (formerly Card Report of Insurance)

OWCP-5a

Work Capacity Evaluation (Psychiatric/Psychological Conditions)

OWCP-5b

Work Capacity Evaluation (Cardiovascular/Pulmonary Conditions)

OWCP-5c

Work Capacity Evaluation (Musculoskeletal Conditions)

OWCP-16

Rehabilitation Plan And Award

OWCP-17

Rehabilitation Maintenance Certificate

OWCP-44

Rehabilitation Action Report



How to Complete a Form

Longshore forms can now be completed using any one of the two options. See below for detailed instructions:

OPTION 1 Print form

  • Select form
  • Print form using the "Print" button on or near the top of the form
  • Write/type in the required information
  • Authorize the form (if applicable) by providing a hand-written signature
  • Mail to the appropriate Longshore District office

OPTION 2 Form-fill

  • Select form
  • Complete the form using your computer keyboard and the <TAB> key or your mouse to navigate between form fields
  • Print the form using the "Print" button on or near the top of the form
  • Authorize the form (if applicable) by providing a hand-written signature
  • Mail to the appropriate Longshore District office

If you have questions about filling/submitting these forms or need other forms assistance, you can send Longshore a question via e-mail at DLHWC-Public@dol.gov. Longshore will respond to your question via e-mail.