Longshore Program

 

 

 

OWCP's  Longshore Program has made the following forms available online. These forms are only available in 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 (click on Adobe Acrobat Reader to download the current version) available on your workstation. These forms can be viewed in an Internet Explorer browser window, but not in other browsers. If you are using Chrome or Firefox, follow these instructions to download PDF files and open them in Adobe Acrobat Reader.

The forms in the list below may be completed manually via the print form option or electronically via the electronic fill option:

Printable Forms

All of the Longshore Program's online forms (with the exception of Forms LS-241 and LS-242) are available to print and to manually fill and submit. Simply click on the appropriate form and print it using the [Print] button provided near the top of the form. Write or type the required information on the hardcopy and authorize the form, if applicable, with a hand-written signature. Once completed, upload the form via SEAPortal (https://seaportal.dol.gov/portal/) or mail to: OWCP/DFELHWC, 400 West Bay Street, Room 63A, Box 28, Jacksonville, FL 32202.

Fillable Forms

Forms (with the exception of Forms LS-241 and LS-242) may be electronically filled. Simply click on the appropriate form, fill out the form using your computer keyboard and the <TAB> key or your mouse to navigate between form fields. Print the form (use the Print button on or near the top of the form), authorize the form (if applicable provide hand-written signature). Once completed, upload the form via SEAPortal (https://seaportal.dol.gov/portal/) or mail to: OWCP/DFELHWC, 400 West Bay Street, Room 63A, Box 28, Jacksonville, FL 32202.

NOTE: When printing these files please remember to use the Adobe Acrobat Reader print icon or the [Print] button on the form, itself, and NOT your browser's print icon on the browser toolbar.

 

Division of Federal Employees' and Longshore and Harbor Workers' Compensation Program (Longshore) Forms
Form NumberOWCP's Form Title/Description
LS-1Request for Examination and/or Treatment
LS-4Attorney Fee Approval Request
LS-5Application for Special Fund Relief
LS-6Commutation Application
LS-7Request for Intervention
LS-8Settlement Approval Request 8(i)
LS-9Stipulation Approval Request
LS-18Pre-Hearing Statement
LS-33Approval of Compromise of Third Person Cause of Action
LS-200Report of Earnings
LS-201Notice of Employee's Injury or Death
LS-202Employer's First Report of Injury or Occupational Illness
LS-203Employee's Claim for Compensation
LS-204Attending Physician's Supplementary Report
LS-207Notice of Controversion of Right to Compensation
LS-208Notice of Payments
LS-210Employer's Supplementary Report of Accident or Occupational Illness
LS-241 / LS-242Notice 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-262Claim for Death Benefits
LS-265Certification of Funeral Expenses
LS-266Application for Continuation of Death Benefit for Student
LS-267Claimant's Statement
LS-271Application for Self-Insurance instructions
LS-272Application to write Longshore Insurance (Carriers)
LS-274Report of Injury Experience of Insurance Carrier or Self-Insured Employer

LS-275ic
Agreement and Undertaking (Insurance Carrier)

LS-275si
Agreement and Undertaking (Self-Insured Employer)
LS-276Application for Security Deposit Determination. State Guarantee Fund Longshore Security Factor Chart
LS-426Request for Earnings Information
LS-513Report of Payments.
LS-570Carrier's Report of Issuance of Policy (formerly Card Report of Insurance)
LS-801Waiver of Service by Registered or Certified Mail for Employers and/or Insurance Carriers
LS-802Waiver of Service by Registered or Certified Mail for Claimants and Authorized Representatives
OWCP-5a

Work Capacity Evaluation (Psychiatric/Psychological Conditions)

 

OWCP-5bWork Capacity Evaluation (Cardiovascular/Pulmonary Conditions)
OWCP-5cWork Capacity Evaluation (Musculoskeletal Conditions)
OWCP-16Rehabilitation Plan And Award
OWCP-17Rehabilitation Maintenance Certificate
OWCP-44Rehabilitation 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 Longshore Central Mail Receipt office or upload to SEAPortal  (preferred method)

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 or electronic signature
  • Mail to the Longshore Central Mail Receipt office or upload to SEAPortal (preferred method)

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