U.S. DEPARTMENT OF LABOR REPORT OF PAYMENTS
Division of Longshore and Harbor Worker's Compensation
Office of Workers’ Compensation Programs
OMB No. 1240-0014
This report is required by law, (33 U.S.C.901 et seq.). Failure to report can result in termination of authorization to provide
coverage. Show number of cases and all payments made during the calendar year under the following acts:
Compensation Act
Authorization
No. of Cases Compensation
Defense Base Act
Nonappropriated Fund
Outer Continental Shelf
District of Columbia
Totals
Compensated PaymentsNumber
Enter “None” in spaces where no payment was made
Company Name and Address Seq. No.
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I certify that I am an officer or official of the insurance company or self-insurer named above and am duly authorized to file
this report, and that I have carefully examined the facts contained herein and they are true to the best of my knowledge.
Any person who knowingly and willfully makes a false statement or conceals a material fact shall be fined not more than
$10,000 or imprisoned not more than five years, or both (18 U.S.C. 1001).
_______________________________________________ ____________________________________________
Signature
Title (Print or Type) Date
Public Burden Statement
Public reporting burden for this collection of information is estimated to average 30 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, 200 Constitution Avenue, N.W., Room C-4319, Washington,
D.C. 20210; and reference the OMB Control Number (1240-0014). Persons are not required to respond to this collection of information
unless it displays a currently valid OMB Control Number.
Form LS-513 (Rev. January 2014)
Longshore
Medical Payments
─ Department of Defense
─ Dep't of Homeland Security
─ Department of State
─ General Services Administration
─ US Agency for Int'l Development
─ Other (Please Specify)
Printed name
_______________________________________________ ____________________________________________
─ Other (Please Specify)
Washington, D.C. 20210
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