Form Ls 203 PDF Details

When an employee experiences an injury related to their work, navigating the process to secure the appropriate compensation and benefits is crucial. The LS-203 form, officially known as the Employee's Claim for Compensation, serves as a fundamental step in this journey. Administered by the U.S. Department of Labor's Office of Workers' Compensation Programs (OWCP), this document facilitates the claim process for workers covered under several federal acts, including the Longshore and Harbor Workers' Compensation Act, Defense Base Act, Outer Continental Shelf Lands Act, and Nonappropriated Fund Instrumentalities Act. By meticulously recording details about the claimant, the nature of the injury, employment information, and the circumstances leading to the injury, the LS-203 form plays an instrumental role in determining an injured worker's eligibility and the extent of compensation and medical benefits they may receive. The form underscores the importance of providing accurate and comprehensive information, as any discrepancies could impact the outcome of the claim. With a strong emphasis on privacy and information security, the form and its instructions ensure that claimants are informed of how their personal information will be used, shared, and protected throughout the process. As the deadline to submit this form is strictly regulated, understanding its components, the accompanying instructions, and the legal implications of the information provided is essential for any claimant seeking benefits due to a work-related injury or illness.

QuestionAnswer
Form NameForm Ls 203
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 203, ls203, 203 workers compensation, ls forms download

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Employee's Claim for Compensation

 

 

 

 

U.S. Department of Labor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office of Workers' Compensation Programs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

See Instructions On Reverse

 

 

Print

 

 

Reset

 

 

 

 

 

 

 

 

 

 

OMB No.1240-0014

 

Expires: 10/31/2023

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Name of person making claim (Type or print)

 

 

 

 

 

 

 

 

 

 

 

1. OWCP No.

 

 

 

 

 

 

 

First

 

MI.

Last

 

 

 

 

 

 

 

 

Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Carrier's No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Claimant's address (number, street, city, state, ZIP code)

 

 

city:

 

 

 

 

 

 

4. Date of Injury

 

 

 

 

 

 

 

line1:

 

 

 

 

 

 

 

 

 

 

state:

zip code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Marital Status

 

 

 

 

 

line2:

 

 

 

 

 

 

 

 

 

 

country: US

 

 

 

 

 

 

Married

 

Single

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Sex

 

8. Date of Birth

9. Social Security # (Required

9a. Nationality

 

10. Did injury cause loss of time beyond day

 

Male

Female

 

 

 

 

 

 

by law)

 

 

 

 

 

 

 

 

 

 

or shift of accident?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Date and time of accident.

 

 

 

(hh:mm am/pm)

 

11a. Did you stop work immediately?

 

 

12. Date and hour pay stopped?

 

 

 

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

Yes

No

 

 

 

 

(mm/dd/yyyy)

(hh:mm am/pm)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Date and hour you returned to work

 

14. Occupation (Job title: longshore worker, welder, etc.)

 

 

15. Injured while doing regular work?

 

(mm/dd/yyyy)

(hh:mm am/pm)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(if "No," explain in Item 24)

 

 

 

 

16. Wages or earnings when injured

a. Weekly

b. Total earnings during year immediately

 

17. Has 3rd party or other claim been made

 

(include overtime allowances, etc.)

 

 

 

 

before injury.

 

 

 

 

because of this Injury?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. Number of years you worked

 

19. Number of days usually

 

20. Name of supervisor at time of accident?

 

 

 

 

 

 

 

for this employer

 

worked per week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. Earliest date supervisor or employer knew of accident

 

 

 

22. Were you employed elsewhere during the week injured?

 

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

No

Yes (If "Yes," state where and when on reverse.)

 

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?

 

Yes

No

 

27. Were you treated by a physician of

 

 

 

(if *Yes," give name and address of doctor, clinic, hospital, etc.)

 

 

your choice?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30. Have you worked during the period

 

 

 

 

 

 

 

 

 

 

 

of disability?

 

 

 

28.

Was such treatment provided by employer?

29. Are you still disabled on account of this injury?

 

No

 

 

 

Yes

 

 

 

Yes

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

31.

Have you received any wages since becoming disabled?

 

32. Has injury resulted in permanent disability, amputation or serious

 

 

 

Yes

No

(if "Yes," give dates on reverse)

 

disfigurement?

Yes (Describe on reverse.)

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33. Name of employer (individual or firm name)

 

 

34. Nature of employer's business

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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, monetary and medical, under the

Signature of claimant

or person acting in his/her behalf

38. Date of this claim

(mm/dd/yyyy)

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

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.

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.gov/portal/?program_name=LS. 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 Federal Employees’, Longshore and Harbor Workers' Compensation

400 West Bay Street, Suite 63A, Box 28

Jacksonville, FL 32202

Use the space below to continue answers. Please number each answer to correspond to the number of the item being continued.

Privacy Act Notice

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.

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.

Public Burden Statement

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 S-3229, Washington, D.C. 20210, and reference the OMB Control Number.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE

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portion of fields in 203 workers compensation

Fill out the Describe in full how the accident, Nature of injury name part of, body affected fractured left leg, Have you received medical, if Yes give name and address of, Yes, Were you treated by a physician of, your choice, Was such treatment provided by, Are you still disabled on account, Yes, Yes, Yes, Have you worked during the period, and of disability fields with any information that can be requested by the application.

203 workers compensation Describe in full how the accident, Nature of injury name part of, body affected fractured left leg, Have you received medical, if Yes give name and address of, Yes, Were you treated by a physician of, your choice, Was such treatment provided by, Are you still disabled on account, Yes, Yes, Yes, Have you worked during the period, and of disability blanks to fill

You'll have to note specific details in the section Use the space below to continue, Privacy Act Notice In accordance, Note The notice applies to all, According to the Paperwork, and Public Burden Statement.

203 workers compensation Use the space below to continue, Privacy Act Notice In accordance, Note The notice applies to all, According to the Paperwork, and Public Burden Statement fields to fill out

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