Information Collection

Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act

IC 43808 under ICR 201409-1240-003 · OMB 1240-0014.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0014 can be found here:

Documents and Forms

Document Name Document Type
Form LS-201 Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act Form
ESA 100.doc Other-Recordkeeping
LS-201 Notice of Employee's Injury or Death ls-201.pdf www.dol.gov/owcp/dlhwc/ls-201.pdf Form
LS-513 Report of Payments LS-513.pdf (DBA changes)3.pdf www.dol.gov/owcp/dlhwc/LS-513.pdf Form
LS-267 Claimant's Statement LS-267.pdf www.dol.gov/owcp/dlhwc/LS-267.pdf Form
LS-203 Employee's Claim for Compensation LS-203 proposed.pdf www.dol.gov/owcp/dlhwc/ls-203.pdf Form
LS-262 Claim for Death Benefits ls-262.pdf www.dol.gov/owcp/dlhwc/ls-262.pdf Form
LS-271 Application for Self-Insurance LS-271.pdf www.dol.gov/owcp/dlhwc/LS-271.pdf Form
LS-204 Attending Physician's Supplementary Report ls-204.pdf www.dol.gov/owcp/dlhwc/ls-204.pdf Form
LS-274 Report of Injury Experience of Insurance Carrier or Self LS-274.pdf www.dol.gov/owcp/dlhwc/LS-274.pdf Form
LS-200 Report of Earnings ls-200.pdf www.dol.gov/owcp/dlhwc/ls-200.pdf Form
DLHWC Seaportal.pdf DLHWC SEA Portal IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 702.111 20 CFR 703.310 20 CFR 702.162 20 CFR 702.201 20 CFR 702.242 20 CFR 702.285 20 CFR 702.321 20 CFR 702.175 20 CFR 702.202 20 CFR 702.174 20 CFR 702.221

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-201	Notice of Employee's Injury or Death	ls-201.pdf	http://www.dol.gov/owcp/dlhwc/ls-201.pdf	Yes	No	Fillable Printable
Form	LS-513	Report of Payments	LS-513.pdf (DBA changes)3.pdf	http://www.dol.gov/owcp/dlhwc/LS-513.pdf	Yes	No	Fillable Printable
Form	LS-267	Claimant's Statement	LS-267.pdf	http://www.dol.gov/owcp/dlhwc/LS-267.pdf	Yes	No	Fillable Printable
Form	LS-203	Employee's Claim for Compensation	LS-203 proposed.pdf	http://www.dol.gov/owcp/dlhwc/ls-203.pdf	Yes	No	Fillable Printable
Form	LS-262	Claim for Death Benefits	ls-262.pdf	http://www.dol.gov/owcp/dlhwc/ls-262.pdf	Yes	No	Fillable Printable
Other-Recordkeeping			ESA 100.doc		No		Paper Only
Form	LS-271	Application for Self-Insurance	LS-271.pdf	http://www.dol.gov/owcp/dlhwc/LS-271.pdf	Yes	No	Fillable Printable
Form	LS-204	Attending Physician's Supplementary Report	ls-204.pdf	http://www.dol.gov/owcp/dlhwc/ls-204.pdf	Yes	No	Fillable Printable
Form	LS-274	Report of Injury Experience of Insurance Carrier or Self-Insured Employer	LS-274.pdf	http://www.dol.gov/owcp/dlhwc/LS-274.pdf	Yes	No	Fillable Printable
Form	LS-200	Report of Earnings	ls-200.pdf	http://www.dol.gov/owcp/dlhwc/ls-200.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/ESA-15	FR Citation: 67 FR 16886

Number of Respondents: 130,036	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	130,036	130,036
Annual IC Time Burden (Hours)	44,955	44,955
Annual IC Cost Burden (Dollars)	46,866	46,866

Documents for IC

Title	Document	Date Uploaded
DLHWC SEA Portal	DLHWC Seaportal.pdf	09/24/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.