OMB control number
Carrier's Report of Issuance of Policy
OMB 1240-0004 · DOL/OWCP.
The Carrier's Report of Issuance of Policy (Form LS-570) is used by authorized insurance carriers to report the policy of insurance issued for each insured employer. This form is to be sent to the Deputy Commissioner in the compensation district indicated by the employer's address. Section 32(a) of the Longshore and Harbor Workers’ Compensation Act (33 USC 932(a)), requires every employer to secure the payment of such compensation with any insurance company authorized by the Secretary, to insure payment of compensation under this Act or receiving authorization from the Secretary to pay such compensation directly.
The latest form for Carrier's Report of Issuance of Policy expires 2028-08-31 and can be found here.
Document Name |
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Form |
Form |
Supporting Statement A |
Supporting Statement A |
 WCPO-2025-0004-DRAFT-0002_Comment_Anonymous.html (document unavailable)Public Comments |
Form LS-570 Carrier's Report of Issuance of Policy
OMB - Supporting Statement for 1240-0004 (LS570) 8-31-2025 - OCIO1.docx
Carrier's Report of Issuance of Policy | Extension without change of a currently approved collection | 2025-07-15 | ||
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Approved without change |
Extension without change of a currently approved collection | 2022-06-10 | |
| No material or nonsubstantive change to a currently approved collection | 2020-12-15 | ||
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Approved without change |
Extension without change of a currently approved collection | 2019-05-31 | |
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Approved without change |
Extension without change of a currently approved collection | 2016-01-29 | |
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Approved without change |
Revision of a currently approved collection | 2015-06-05 | |
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Preapproved |
No material or nonsubstantive change to a currently approved collection | 2015-03-12 | |
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Approved without change |
Revision of a currently approved collection | 2012-12-11 | |
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Approved without change |
Existing collection in use without an OMB Control Number | 2010-03-12 |