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Office of Workers' Compensation Programs

Division of Longshore and Harbor Workers' Compensation (DLHWC)

CHAPTER 10-200 — FORMS

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