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U.S. Department of Labor Employee's Claim for Compensation (Department of Labor)

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U.S. Department of Labor
Office of Workers' Compensation Programs
Employee's Claim for Compensation
OMB No.1240-0014
See Instructions On Reverse
3. Name of person making claim (Type or print)
MI.
Last
First
5. Claimant's address (number, street, city, state, ZIP code)
6. Marital Status
10. Did injury. cause loss of time beyond day
or shift of accident?
9. Social Security # (Required8. Date of Birth
7. Sex
Yes No
Female
Male
17. Has 3rd party or other claim been made
because of this Injury?
b. Total earnings during year immediately
before injury.
a. Weekly
16. Wages or earnings when injured
(include overtime allowances, etc.)
Yes
No
19. Number of days usually
worked per week
20. Name of supervisor at time of accident?18. Number of years you worked
for this employer
22. Were you employed elsewhere during the week injured?
21. Earliest date supervisor or employer knew of accident
(If "Yes," state where and when on reverse.)
Yes
No
23. Exact place where accident occurred (Street address, city, town, name of vessel, pier, terminal, etc.)
24. Describe in full how the accident occurred (Relate the events which resulted in the injury or occupational disease. Tell what the injured was
doing at the time of the accident. Tell what happened and how it happened. Name any objects or substances involved and tell how they
were involved. Give full details on all factors which led or contributed to the accident. If more space is needed, continue on reverse.)
25. Nature of injury (name part of
body
affected - fractured left leg,
bruised
right thumb, etc. If there
was a loss
or loss of use of a part
of the body.
describe.)
26. Have you received medical attention for this injury?
(if *Yes," give name and address of doctor, clinic, hospital, etc.)
No
Yes
29. Are you still disabled on account of this injury?28. Was such treatment provided by employer?
Yes
No
No
Yes
35. Address of employer (Number, street, city, state, ZIP code)
36. If accident occurred outside the U.S.,
state whether you are a U.S. Citizen
Yes
No
37. I hereby make claim for compensation benefits,
38. Date of this claim
Signature of claimant
or person acting in his/her behalf
Section 31(a)(1) of the Longshore 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 on conviction thereof shall be punished by a fine not to exceed $10,000, by
imprisonment not to exceed five years, or by both.
Form LS-203
Rev. August 2014
Married Single
line1:
line2:
(hh:mm am/pm)
(mm/dd/yyyy)
(hh:mm am/pm)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
1. OWCP No.
4. Date of Injury
11. Date and time of accident.
11a. Did you stop work immediately?
Yes No
12. Date and hour pay stopped?
13. Date and hour you returned to work
14. Occupation (Job title: longshore worker, welder, etc.)
Yes No
(if "No," explain in Item 24)
27. Were you treated by a physician of
your choice?
Yes
No
30. Have you worked during the period
of disability?
Yes
No
31. Have you received any wages since becoming disabled?
(if "Yes," give dates on reverse)
Yes
No
32. Has injury resulted in permanent disability, amputation or serious
disfigurement?
Yes (Describe on reverse.)
No
33. Name of employer (individual or firm name)
34. Nature of employer's business
2. Carrier's No.
15. Injured while doing regular work?
monetary and medical, under the
Telephone No.
city:
state:
country:
zip code:
by law)
9a. Nationality
(hh:mm am/pm)
(mm/dd/yyyy)
Print
Reset
United States
Instructions
• Use this form to file a claim under any one of the following laws:
Longshore and Harbor Workers' Compensation Act
Defense Base Act
Outer Continental Shelf Lands Act
Nonappropriated Fund Instrumentalities Act
- Applicant may leave items 1. and 2. blank.
Except as noted below, 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. The 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. Persons are not
required to respond to this collection of information unless it displays a currently valid OMB control number. The information will be used to determine
an injured worker's entitlement to compensation and medical benefits.
In case of hearing loss, a claim may be filed within one year after receipt by an employee of an audiogram, with the accompanying report thereon,
indicating that the employee has suffered a loss of hearing.
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 this form.
Use the space below to continue answers. Please number each answer to correspond to the number of the item being continued.
Privacy Act Notice
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a) you are hereby notified that (1) the Longshore and Harbor Workers' Compensation
Act, 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 personal information on claimants and their immediate families. (2) Information which the Office has will be used to
determine eligibility for and the amount of benefits payable 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 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 matter arising in connection with the claim.
(6) Information may be given to the 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 or have been paid properly, and where appropriate, to pursue salary/administrative offset and debt
collection actions required or permitted by law. (7) Disclosure of the claimant's Social Security Number (SSN) or tax identifying number (TIN) on this form is
mandatory. The SSN and/or TIN and other information maintained by the Office may be used for identification, and for other purposes authorized by law. (8)
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
Note: The notice applies to all forms requesting information that you might receive from the Office in connection with the processing
and/or adjudication of the claim you filed under the LHWCA and related statutes.
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 15 minutes 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. ( 33 U.S.C.913(a) ). Send comments regarding the
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, NW, Room C-4319, Washington, D.C. 20210, and reference the OMB Control Number.
If you have already been assigned an OWCP Case Number, please include your OWCP case number and submit electronically to the file through the DLHWC’s
Secure Electronic Access Portal (SEAPortal) https://seaportal.dol-esa.gov. Alternatively, to submit the claim by mail, please be sure to include your case
number and mail to the Central Mail Receipt site at the address shown below.
If this is a new claim, and you do not have an OWCP Case Number, please submit the form through the Case Create Fax Number (202) 513-6814.
Alternatively, to submit the "case create" form by mail, please send it to the address below:
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
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U.S. Department of Labor Employee's Claim for Compensation (Department of Labor)

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Completed 19 July 2020

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