U.S. Department of Labor
Payment Of Compensation Without Award
(Longshore and Harbor Workers' Compensation Act,
Office of Workers' Compensation Programs
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
Rev. January 2015
2. CARRIER'S No.1. OWCP No.
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.
DO NOT SEND COMPLETED FORMS TO THIS OFFICE.
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