7. Do you maintain a medical facility for the care of injured employees?
[ Yes (Describe equipment and service)
[ No (Specify arrangements you have made)
8. Which do you intend to do?
a. [ Deal directly with employees in
compensation matters
(If you have checked "a", give name and address of persons responsible for claims handling, with brief
resume of their experience. If you have checked "b", give name and address of the organization, and
describe the arrangements, including what, if any, experience the organization has in Longshore.)
b. [ Deal through an insurance service
organization
9.
ACCIDENT EXPERIENCE FOR PREVIOUS YEARS
YEAR
20
20 20
a. Number of deaths
b. Number of permanent total disability cases
c. Number of permanent partial disability cases (Schedule losses only)
d. Number of injuries not included in a, b, and c above, causing disability more than
three days
TOTALS
11. Incorporated under laws of what state? 10. Date of incorporation (mm/dd/yyyy) 12. Date applicant was established (if not a
corporation) (mm/dd/yyyy)
13. Did you succeed anyone? (If "Yes", state whom)
[ Yes No
14. Name of President 15. Name of Vice President
16. Name of Treasurer 17. Name of Secretary
CORPORATE SEAL
18. I certify that I am an official of the above named applicant, duly authorized to file this application, that I
have carefully examined the foregoing statements, and the facts herein are true.
Signature
19. Name and Title
20. Date of this application (mm/dd/yyyy)
DO NOT WRITE IN THE ITEMS BELOW
21. Date application received 22. OWCP Certification
PRIVACY ACT STATEMENT
The Privacy Act of 1974 as amended (5 U.S.C. 522a), section 901 of Title 33 to the US Code and 33 U.S.C. 932 (a) authorize collection of this information.
The purpose of this information is to determine an applicant's qualifications as a self-insurer under the Longshore and Harbor Workers' Compensation Act
(LWHCA). Completion of this form is not mandatory; however, failure to provide the information may result in the denial of request to self insure. Additional
disclosures of this information may be to: (1) the employer which employed the claimant at the time of injury, or to the insurance carrier or other entity which
secured the employer's compensation liability. (2) physicians and other medical service providers for use in providing treatment or medical/vocational
rehabilitation, making evaluations and for other purposes relating to the medical management of the claim. (3) the Department of Labor's Office of
Administrative Law Judges (OALJ), or other person, board or organization, which is authorized or required to render decisions with respect to the claim or
other matter arising in connection with the claim. (4) Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a
decision under the LHWCA to determine whether benefits are being and have been paid properly, and where appropriate, to pursue salary/administrative
offset and debt collection actions required or permitted by law. (5) Failure to disclose all requested information may delay the processing of the claim, the
payment of benefits, or may result in an unfavorable decision or reduced level of benefits.
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid
OMB control number. Public reporting burden for this collection of information is estimated to average 3 hours per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Use of
this form is optional, however furnishing the information is required in order to obtain and/or retain benefits. Send comments regarding this burden estimate
or any aspect of this collection of information, including suggestions for the reducing of this burden, to the U.S. Department of Labor, 200 Constitution
Avenue, NW, Room C-4319, Washington, D.C. 20210 and reference the OMB Control Number.
Telephone
