Approval of Compromise of Third
Person Cause of Action
U.S. Department of Labor
Claimant
OWCP Case No.
V.
Employer
Insurance Carrier
The above named employer and its insurance carrier, having liability for disability/death benefits under the
Act in the above captioned case, and being advised that the claimant or representative above named has
compromised the cause of action against
third person(s), which arose out of the injury/death on
in the case, in the gross amount of $ , and the net amount of $
herewith approves said compromise on the date shown below, pursuant to the
dated
Employer
By
Title Date
Insurance Carrier
By
Title
Date
Claimant
By
Title Date
Filed on
District Director
Date
This form, or a signed statement in lieu thereof containing language of the same intent, must be filed in the
office of the District Director having jurisdiction of the subject injury or death within 30 days after
compromise is made in order to insure that
the employer shall be liable for compensati on
as provided
in section 33.
Form LS-33
Rev. Jan. 2003
2IILFHRI:RUNHUV&RPSHQVDWLRQ3URJUDPV
provisions of Sec. 33(g) of the Longshore and Harbor Workers' Compensation Act, 33 U.S.C. 933(g).
District
Compensation
in the Office of the District Director for the
