Insurance Carrier or Self-Insured Employer's Name
(i & j)
(a) (b) (c) (d) (f) (g)
(i) (j) (k)
(l) (m)
Office of Workers' Compensation
Rev. April 2009
The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the following information is 20
CFR 703.212(3) and 20 CFR 703.311(2). Use of this form is optional, however failure to submit the completed report may result in termination of your authorization to write insurance or be self-insured under the
Act(s). 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 1240-0014. The time required to complete this information collection is estimated to average 60 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 aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Longshore and Harbor Workers' Compensation, Room C-4319,
Public Burden Statement
Name of Injured Employee Date of
Date of this report
Estimate of
List all open cases as of
Dec. 31, ______________
Estimate of
Future Medical
(Disability cases
Estimate of Total
Report of Injury Experience of Insurance
Carrier or Self-Insured Employer
Insurance Carrier/ Self- Insured Employer Address
(Number, Street, City, State, ZIP Code)
Injury Year
Total Amount
of Benefits
Paid to date
CY Compen-
sation Paid
CY Medical
Nature of Injury
Use Abbreviations -Fx,
spr, etc.
U.S. Department of Labor
This report is to be used to list all open cases as of the date of the report. The information provided will be used to
determine the adequacy of a carrier's or self - insurer's security deposit.
Social Security
st zip
Washington, DC 20210.
OMB No. 1240-0014
Division of Longshore and Harbor Workers' Compensation
1. A separate report must be submitted for each act, each state and for each year of payments.
2. Show the carrier/self insurance authorization number on each report.
3. If the company has subsidiaries, separate report for each state, each act and each year of payment must be submitted for each subsidiary.
4. Each report must be listed chronologically by accident date and include:
Column a- the claimant’s social security number;
Column b- the OWCP case number;
Column c- the name of the injured employee;
Column d- the date of injury;
Column e- the nature of injury;
Column f- the amount of compensation and medical payment paid through the reporting year;
Column g- the amount of compensation paid during the calendar year reported on form LS-513;
Column h- the amount of medicals paid during the calendar year reported on form LS-513;
Column i- the estimate of future compensation benefit payments;
Column j- the estimate of future medical benefit payments;
Column k- the estimate total compensation and medical payments expected to be paid in the future;
Column l- a checkmark if the case is a fatal case; and
Column m- a checkmark if the case is a third party case.
5. Each report should reflect a total for all estimated future payments for that act, state and reporting year.
6. A separate report showing the grand totals for all states by Act should also be submitted.
The report should be addressed as follows: US Department of Labor
OWCP/DLHWC, Room C-4319
200 Constitution Avenue, NW
Washington, DC 20210
Attn: Douglas Fitzgerald, Director, DLHWC
For further information and or assistance, please contact the Insurance Branch at 202-693-0038.
Failure to submit the complete report as outlined in these instructions may result in termination of your authorization to write insurance or be self-insured under the Act(s). This insurance or self insurance
authorization cannot be transferred or assigned. Any change involving the corporate name, structure, ownership, organization, etc. may affect the insurance carrier/self insurer’s authority and must be brought to
the attention of this Office prior to the effective date of the event.
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. (7) 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
Section 31 (a) (1) of the Longshore and Harbor Workers’ Compensation Act, 33 U.S. C. 931(a) (1), provides as follows: Any claimant or representative of a claimant who knowingly and willfully makes a false
statement or representation for the purpose of obtaining a benefit or payment under this Act shall be guilty of a felony, and or conviction thereof shall be punished by a fine not to exceed $10,000, by
imprisonment not to exceed five years, or both.
All carriers and self- insured employers are required to submit this report on an annual basis, as required by 20 CFR 703.212(3) and 20 CFR 703.311 (2).
7. All submitted reports must include a separate notarized statement on company letter, signed by a corporate officer attesting to a completeness and accuracy of the information reported. This statement must
also indicate the name and telephone number of the person to be contacted in the event there are questions.
Privacy Act Notice
(1) The Longshore and Harbor Workers' Compensation Act (LHWCA), as amended and extended (33 U.S.C. 901 et seq.) LHWCA is administered by the Office of Workers’ Compensation Programs of the U.S.
Department of Labor which receives and maintains information on claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for the amount of benefits
under the LHWCA. (3) Information may be given to 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.
(4) Information may be given to the 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. (5) Information may be given to 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 matters arising in connection with the claim. (6) Information may be given to Federal, state and local agencies for law enforcement purposes, to obtain