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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 43808 under ICR 202502-1240-005 · OMB 1240-0014.

Documents and Forms
Document Name
Document Type
Other-Recordkeeping
Other-Recordkeeping
Instruction
Instruction
Instruction
Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Regulations Governing the Administration of the Longshore and Harbor Workers' Compensation Act
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 702.101 20 CFR 702.111 20 CFR 702.162 20 CFR 702.174 20 CFR 702.175 20 CFR 702.201 20 CFR 702.202 20 CFR 702.221 20 CFR 702.242 20 CFR 703.285 20 CFR 702.310 20 CFR 702.321

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Recordkeeping ESA 100.doc No   Paper Only
Instruction LS-272instructions1.pdf https://www.dol.gov/owcp/dlhwc/LS-272instructions.pdf Yes No Paper Only
Instruction LS-271instructions(1).pdf https://www.dol.gov/owcp/dlhwc/LS-271instructions.pdf Yes No Paper Only
Form and Instruction LS-200 Report of Earnings ls-200.pdf https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-200.pdf Yes Yes Fillable Fileable
Form and Instruction LS-201 Notice of Employee's Injury or Death ls-201 post-1-20-25 updated version.pdf https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-201.pdf Yes Yes Fillable Fileable
Form and Instruction LS-203 Employee's Claim for Compensation ls-203 post-1-20-25 updated version.pdf https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-203.pdf Yes Yes Fillable Fileable
Form and Instruction LS-204 Attending Physician's Supplementary Report ls-204.pdf https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-204.pdf Yes Yes Fillable Fileable
Form and Instruction LS-262 Claim for Death Benefits ls-262.pdf https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-262.pdf Yes Yes Fillable Fileable
Form and Instruction LS-267 Claimant's Statement LS-267.pdf https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-267.pdf Yes Yes Fillable Fileable
Form and Instruction LS-272 Application to write Longshore Insurance LS-272.pdf https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-272.pdf Yes Yes Fillable Fileable
Form and Instruction LS-274 Report of Injury Experience of Insurance Carrier or Self-Insured Employer LS-274.pdf https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-274.pdf Yes Yes Fillable Fileable
Form and Instruction LS-271 Application for Self-Insurance LS-271.pdf https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/LS-271.pdf Yes Yes Fillable Fileable
Form and Instruction LS-513 Report of Payments LS-513.pdf https://www.dol.gov/sites/dolgov/files/owcp/dlhwc/ls-513.pdf Yes Yes Fillable Fileable

Income Security General Retirement and Disability

DOL/OWCP-3  67 FR 16886

45,217 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 76,417 0 0 0 0 76,417
Annual IC Time Burden (Hours) 21,155 0 0 0 0 21,155
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.