Fillable Notice of Controversion of Right to Compensation U.S. (Department of Labor)

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Notice of Controversion of Right to Compensation U.S. (Department of Labor)

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Notice of Controversion of Right
to Compensation
U.S. Department of Labor
Office of Workers' Compensation Programs
Longshore and Harbor Workers' Compensation
This report is required to obtain or retain benefits and is authorized by law and regulation (33 U.S.C. 914(d), (e); 20 C.F.R. §702.251).
Failure to report when controverting right to compensation can result in liability for 10 percent additional compensation.
OMB No. 1240-0042
Instructions: This form may be used by the employer/carrier to controvert the right to compensation. 33 U.S.C.
914(a) requires the employer to pay compensation promptly and without an award unless the right to such
compensation is controverted by the filing of this form. Failure either to pay each installment of compensation, or
controvert the right to such compensation, within fourteen days after it becomes due may result in liability for
additional compensation equal to ten percent of each installment not paid when due (33 U.S.C. 914(d), (e)). If
the right to compensation is controverted, this form should be submitted to the District Director through the
OWCP/DLHWC Central Mail Receipt site or uploaded directly to the case file at:
https://seaportal.dol-esa.gov,
and the reasons for such controversion should be fully stated in item 12. A copy of the completed form must be
mailed to the claimant and claimant's representative.
1. OWCP File No.
2. Employer File No.
3. Carrier File No.
4. Claimant's Name and Address
First Name
name:
line 1: line 2:
state:
country:
8. Claim Filed or Injury Reported Under (check one)
LHWCA
OCSLA
DCWCA
NFIA
DBA
9. Nature of Injury or Occupational Disease
11. Date of Employer's First Knowledge of Injury (Month, Day, Year)
6. Employer's Name, Address and Phone Number
5. Employee's Name and Address if different from Claimant's
7. Carrier's Name, Address and Phone Number
10. Date of Injury (Month, Day, Year)
12. Right to compensation is controverted for the following reason(s):
14. Print Name and Phone Number
15. Title
13. Authorized Signature
16. Date of this Notice (Month, Day, Year)
Form LS-207
zip:
city:
M.I.
Rev. May 2015
Last Name
zip:
zip:
zip:
city:
city:
city:
country:
phone:
st:
st:
st:
telephone:
country:
As verified by the signature below, this form was mailed to the claimant and claimant's representative.
This is notice that the employer (or its insurance carrier) makes objection to your right to
benefits under the workers' compensation Act indicated in item 8 of this form, for the injury or
death identified in items 9 and 10. Item 12 gives the reasons for this objection. If you believe
you are entitled to workers' compensation benefits under the LHWCA and its extensions, or
disagree with the grounds stated, please inform your servicing district office, giving reasons
for your belief. For further instructions, please see the reverse side of this form.
Explanation
to
Employee
country:
telephone:
telephone:
Expires: 09-30-2021
telephone:
Print
Reset
US
US
US
US
INSTRUCTIONS TO INJURED WORKER AND BENEFICIARY
A claim may be filed within one year after the injury or death (33 U.S.C. 913(a)). If compensation has been paid
without an award, a claim may be filed within one year after the last payment. Time for filing a claim does not
begin to run until the employee or beneficiary knows, or should have known by the exercise of reasonable
diligence, of the relationship between the employment and the injury.
In cases involving occupational disease which does not immediately result in death or disability, a claim may
be filed within two years after the employee or claimant becomes aware, or in the exercise of reasonable
diligence or by reason of medical advice should have been aware, of the relationship between the
employment, the disease, and the death or disability.
To file a claim for compensation benefits, complete and sign Form LS-203, Employee's Claim for Compensation
or Form LS-262, Claim for Death Benefits. The form can be obtained through the OWCP/DLHWC website at:
http://www.dol.gov/owcp/dlhwc/lsforms.htm or by your servicing district office. The contact information is
available on the OWCP/DLHWC website at: http://www.dol.gov/owcp/dlhwc/lscontactmap.htm.
Please be sure to include the OWCP Case Number and mail this form to the OWCP/DLHWC Central Mail
Receipt site at the following address:
U. S. Department of Labor
Office of Workers' Compensation Programs
Division of Longshore and Harbor Workers' Compensation
400 West Bay Street, Suite 63A, Box 28
Jacksonville, FL 32202
Or upload the claim directly to the case file using the Secure Electronic Access Portal (SEAPortal).
Access the SEAPortal directly at: https://seaportal.dol-esa.gov
The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. §522a) and the Paperwork Reduction Act of 1995, as
amended. The authority for requesting the following information is 20 C.F.R. §702.251. Use of this form is optional, however furnishing the
information is required in order to obtain and/or retain benefits. According to the Paperwork Reduction Act of 1995, an agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 1240-0042. The time required to complete this information collection is estimated to average 15
minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Longshore and Harbor Worker's
Compensation, Room C4319, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
DO NOT SEND COMPLETED FORMS TO THIS OFFICE.
PRIVACY ACT STATEMENT
Privacy Act of 1974 as amended (5 U.S.C. §552a), section §914(d) of Title 33 to the U.S. Code and 20 C.F.R. §702.251 authorizes collection of
this information. The purpose of this information is to inform the claimant of the reason(s) the insurance carrier or self-insured employer makes
objection to paying compensation or medical benefits and to determine eligibility for the amount of benefits payable under the Longshore and
Harbor Workers' Compensation Act and its extensions (LHWCA). Completion of this form is not mandatory; however, failure to provide the
information may result in additional compensation benefits payable by the employer (33 U.S.C. §914 (e)). Additional disclosures of this information
may be to: (1) The claimant and/or his representative. (2) 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. (3) Physicians and other medical service providers for use in providing
treatment or medical/vocational rehabilitation, making evaluations and for other purposes relating to the management of the claim. (4) 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. (5) 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. (6) Failure to
disclose all requested information may delay the processing of the claim, the payment of additional benefits, or may result in an unfavorable
decision or reduced level of benefits.
PUBLIC BURDEN STATEMENT
Rev. May 2015
Form LS-207
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Notice of Controversion of Right to Compensation U.S. (Department of Labor)

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Completed 26 January 2021

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