U.S. Department of Labor
Payment Of Compensation Without Award
(Longshore and Harbor Workers' Compensation Act,
Office of Workers' Compensation Programs
as extended)
Expires: 01-31-2018
NOTE: This Notice is to be filed with the District Director not later than the same day that first
payment is made. A copy should be sent to the payee(s) AND to their attorney (if represented).
3. Name of injured person (First, middle, last - please print or type)
4. Address of injured person (Include number, street, city, state and zip code. Add country if not United States.)
6. Date disability began (Month, day, year)
5. Date of accident or first illness (Month, day, year)
7. Name of injured, or dependents of injured, to whom compensation will be paid
multiplied by 2/3 compensation rate $
Average weekly wage $
(Mark if maximum rate is being paid)
9b. Payment Begin Date (Month, day, year)
9a. Type of compensation paid.
I0. Date of first payment (Month, day, year)
11. Has medical care and treatment been provided by a physician or hospital chosen by the injured person?
(Mark appropriate box)
12. Name and address of employer (Include name, number, street, city, state and zip code. Add country if not United States.)
13. Name and address of insurance carrier and/or claim administrator (Include name, number, street, city, state and zip code. Add country
if not United States.)
14. Authorized signature
16. Date signed(mm-dd-yyyy)
15. Type or print title and name of person whose signature appears in item 14
Form LS-206
Rev. January 2015
Phone number
Public Burden Statement
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 accordance with
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.
displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes per response,
20CFR 702.234. Send comments regarding the burden estimate or any other aspect of this collection of information, including
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection
9c. Is the employer continuing to pay the injured person's salary?
9d. If so, are these salary continuation payments being made in
lieu of compensation payments?
OMB No. 1240-0043
United States
United States
United States
The Privacy Act of 1974 as amended (5 U.S.C. 552a), section 901 of Title 33 to the US Code and 33 U.S.C. 914 (b)
and (c) authorize collection of this information. The purpose of this information is to determine the payment status
of a given case under the Longshore and Harbor Workers' Compensation Act (LHWCA). Completion of this form
is not mandatory; however, furnishing the information is required in accordance with 20CFR 702.234. Additional
disclosures of this information may be to: (1) 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. (2) 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. (3) 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. (4) 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. (5) 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.