Longshore Program
OWCP's Longshore Program has made the following forms available online. These forms are only available in PDF format. In order to view and/or print PDF documents you must have a PDF viewer. It is highly recommended that you have the most current version (click on Adobe Acrobat Reader to download the current version) available on your workstation. These forms can be viewed in an Internet Explorer browser window, but not in other browsers. If you are using Chrome or Firefox, follow these instructions to download PDF files and open them in Adobe Acrobat Reader.
The forms in the list below may be completed manually via the print form option or electronically via the electronic fill option:
Printable Forms
All of the Longshore Program's online forms (with the exception of Forms LS-241 and LS-242) are available to print and to manually fill and submit. Simply click on the appropriate form and print it using the [Print] button provided near the top of the form. Write or type the required information on the hardcopy and authorize the form, if applicable, with a hand-written signature. Once completed, upload the form via SEAPortal (https://seaportal.dol.gov/portal/) or mail to: OWCP/DLHWC, 400 West Bay Street, Room 63A, Box 28, Jacksonville, FL 32202.
Fillable Forms
Forms (with the exception of Forms LS-241 and LS-242) may be electronically filled. Simply click on the appropriate form, fill out the form using your computer keyboard and the <TAB> key or your mouse to navigate between form fields. Print the form (use the Print button on or near the top of the form), authorize the form (if applicable provide hand-written signature). Once completed, upload the form via SEAPortal (https://seaportal.dol.gov/portal/) or mail to: OWCP/DLHWC, 400 West Bay Street, Room 63A, Box 28, Jacksonville, FL 32202.
NOTE: When printing these files please remember to use the Adobe Acrobat Reader print icon or the [Print] button on the form, itself, and NOT your browser's print icon on the browser toolbar.
| Form Number | OWCP's Form Title/Description |
|---|---|
| LS-1 | Request for Examination and/or Treatment |
| LS-4 | Attorney Fee Approval Request |
| LS-5 | Application for Special Fund Relief |
| LS-6 | Commutation Application |
| LS-7 | Request for Intervention |
| LS-8 | Settlement Approval Request 8(i) |
| LS-9 | Stipulation Approval Request |
| LS-18 | Pre-Hearing Statement |
| LS-33 | Approval of Compromise of Third Person Cause of Action |
| LS-200 | Report of Earnings |
| LS-201 | Notice of Employee's Injury or Death |
| LS-202 | Employer's First Report of Injury or Occupational Illness |
| LS-203 | Employee's Claim for Compensation |
| LS-204 | Attending Physician's Supplementary Report |
| LS-207 | Notice of Controversion of Right to Compensation |
| LS-208 | Notice of Payments |
| LS-210 | Employer's Supplementary Report of Accident or Occupational Illness |
| LS-241 / LS-242 | Notice to Employees (This form is provided by the Insurance Carrier when the policy is issued. Employers should request from their carrier. Carriers and self-insurers should request from their corporate compliance department.) |
| LS-262 | Claim for Death Benefits |
| LS-265 | Certification of Funeral Expenses |
| LS-266 | Application for Continuation of Death Benefit for Student |
| LS-267 | Claimant's Statement |
| LS-271 | Application for Self-Insurance instructions |
| LS-272 | Application to write Longshore Insurance (Carriers) |
| LS-274 | Report of Injury Experience of Insurance Carrier or Self-Insured Employer |
LS-275ic | Agreement and Undertaking (Insurance Carrier) |
LS-275si | Agreement and Undertaking (Self-Insured Employer) |
| LS-276 | Application for Security Deposit Determination. State Guarantee Fund Longshore Security Factor Chart |
| LS-426 | Request for Earnings Information |
| LS-513 | Report of Payments. |
| LS-570 | Carrier's Report of Issuance of Policy (formerly Card Report of Insurance) |
| LS-801 | Waiver of Service by Registered or Certified Mail for Employers and/or Insurance Carriers |
| LS-802 | Waiver of Service by Registered or Certified Mail for Claimants and Authorized Representatives |
| OWCP-5a* | Work Capacity Evaluation Psychiatric/Psychological Conditions |
| OWCP-5a (En Español)* | Evaluación de la capacidad de trabajo Condiciones psiquiátricas / psicológicas |
| OWCP-5b* | Work Capacity Evaluation Cardiovascular/Pulmonary Conditions |
| OWCP-5b (En Español)* | Evaluación de la capacidad de trabajo Condiciones cardiovasculares / pulmonares |
| OWCP-5c* | Work Capacity Evaluation for Musculoskeletal Conditions |
| OWCP-5c (En Español)* | Evaluación de la capacidad de trabajo Condiciones músculo esqueléticas |
| OWCP-16 | Rehabilitation Plan And Award |
| OWCP-17 | Rehabilitation Maintenance Certificate |
| OWCP-44 | Rehabilitation Action Report |
How to Complete a Form
Longshore forms can now be completed using any one of the two options. See below for detailed instructions:
OPTION 1 Print form
- Select form
- Print form using the "Print" button on or near the top of the form
- Write/type in the required information
- Authorize the form (if applicable) by providing a hand-written signature
- Mail to the Longshore Central Mail Receipt office or upload to SEAPortal (preferred method)
OPTION 2 Form-fill
- Select form
- Complete the form using your computer keyboard and the <TAB> key or your mouse to navigate between form fields
- Print the form using the "Print" button on or near the top of the form
- Authorize the form (if applicable) by providing a hand-written or electronic signature
- Mail to the Longshore Central Mail Receipt office or upload to SEAPortal (preferred method)
If you have questions about filling/submitting these forms or need other forms assistance, please visit our Frequently Asked Questions, or alternatively you can send Longshore a question via e-mail at DLHWC-Public@dol.gov. Longshore will respond to your question via e-mail.