Division of Longshore and Harbor Workers' Compensation (DLHWC)
Industry Notice 126
May 11, 2009
Notice No. 126
NOTICE TO INSURANCE CARRIERS AND SELF-INSURED EMPLOYERS UNDER THE LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT, AND OTHER INTERESTED PERSONS
SUBJECT: Newly Revised Forms LS-206, LS-207 and LS-208
Mandatory Longshore Forms LS-206, Payment of Compensation Without Award, LS-207. Notice of Controversion, and LS-208, Notice of Final Payment or Suspension of Compensation Payments, have been revised in November and December 2008. These revised forms are now available for download, printing, and electronic filing on the DLHWC website. http://www.dol.gov/owcp/dlhwc/lsforms.htm.
Effective May 11, 2009, the revised versions of these three forms should be used. All prior versions of the forms are obsolete.
The December 2008 version of the Form LS-206 contains changes and requires the following mandatory information and action:
- The instruction section at the top of the form has been revised to require a copy of the form to be sent to the payees AND to their attorney. This action ensures that the benefit recipients as well as their legal representatives receive notice that compensation payments have started or have been reinstated.
- The name and address of the Employer previously shown in Box 12 and Box 13 of the form are now shown in one single box, Box 12. If the employer is located outside the United States, the postal code and the country should be included.
- In the revised form, the name and address of the Insurance Carrier or the self-insured employer’s Claims Administrator are shown in Box 13. If it is located outside the United States, the postal code and country must be shown.
- In addition to the title, the revised form requires the name and phone number of the person whose signature appears on the form to be shown in Box 15. This information allows the Longshore District Office and any interested party to readily identify and to contact the individual should there be questions regarding the information provided.
The December 2008 version of the Form LS-207 incorporates the following changes:
- In Box 7 and Box 8, the Self-Insured Employer and the Insurance Carrier (or the Claims Administrator) must include their telephone number in addition to their names and addresses. This information allows the Longshore District Office and any interested party to readily contact the employer or carrier should additional information be required.
- Box 14 has been revised so that the person signing the form must print his or her name and give a phone number. This information allows the Longshore District Office and any interested party to readily identify and to contact the individual should there be questions regarding the information provided.
- The title of the person signing the form has been moved from Box 14 to a new Box 15.
The November 2008 version of the Form LS-208 contains several substantive changes and requires the following mandatory action and information:
- The Self-Insured Employer (or its Claims Administrator) or the Insurance Carrier must send the original Form LS-208 to the Longshore District Office and send copies to the Employer, the Employee (or Beneficiary if a death claim), and the Employee's Legal Representative (attorney), if one has been appointed. The person filing the form must check all applicable boxes at the bottom of the Form LS-208 to indicate the parties to whom copies have been sent. This action ensures that all parties to the claim receive timely notice when compensation has been suspended or terminated.
- In Box 3a, the address of the Longshore District Office where the Form LS-208 is filed must be shown in full. This information facilitates inquiries to the District Office should there be questions regarding the reported payments.
- In Box 7a, the date of first payment of compensation must be shown. This date is the date of the first compensation (indemnity or death benefit) check issued in the claim. This information should be identical to the date on Box 10 of the Form LS-206, Payment of Compensation Without Award. This information allows the District Office to determine if interest and/or additional compensation under Sections 14(e) and 14(f) of the Act should be assessed.
- In box 14, only benefits actually paid should be reported. Enter on a separate line each type of disability payment at a different rate. Use a separate sheet if additional space is required. This information allows the District Office to determine if benefits were paid appropriately.
- In Box 15a, if compensation payments have been made to beneficiaries in a death claim, in addition to the names of the beneficiaries, their Dates of Birth must be shown. This information allows the District Office to determine the appropriate benefits paid to children and students.
- In Box 15c, space is available to report the $5000 payment to the Special Fund under § 44(c) of the Act, i.e., when there is no eligible survivor for death benefits.
- In Box 16, space is available to report other payments such as additional compensation under Sections 14(e) and 14(f) of the Act, Section 8(i) settlements, and commutation under Section 9(g) of the Longshore Act or Section 2(b) of the Defense Base Act.
- In Box 17a, the phone number of the person signing the form must be shown. This allows the District Office to contact the individual should there be questions regarding the reported payments.
Questions regarding the revised forms should be addressed in writing to MICHAEL NISS, Director, Division of Longshore and Harbor Workers' Compensation, Office of Workers’ Compensation Programs, 200 Constitution Avenue NW, Rm C-4315, Washington, DC 20210.
Director, Division of
Longshore and Harbor