Initiating the process of compensating workers who have encountered injuries or illnesses during their service in harbors or longshore operations is marked by the use of the LS-206 form, "Payment Of Compensation Without Award." As a cornerstone document guided by protocols established under the U.S. Department of Labor's Office of Workers' Compensation Programs and tailored for compliance with the Longshore and Harbor Workers' Compensation Act, the importance of this form cannot be overstated. The LS-206 form serves a dual purpose; not only does it notify the District Director of the commencement of compensation payments on the very day the first payment is made, but it also ensures that both the injured party and, if applicable, their legal representative are kept in the loop with a provided copy. This procedural step marks the initial move towards financial reassurance for the injured or ill workers by detailing vital information such as the individual's name, address, the date of the accident or onset of illness, and the specifics of the compensation to be paid, including the average weekly wage and compensation rate. Furthermore, it addresses aspects concerning ongoing medical care, the identity of the employer, and insurance carrier details, solidifying its role as an essential instrument in the administration of workers' compensation. With a structured format that demands attention to detail, the submission of this form aligns with regulatory requirements mandated by 20CFR 702.234, thereby underscoring its significance in the broader context of workers' welfare and rights under relevant labor laws.
| Question | Answer |
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| Form Name | Form Ls 206 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | 2011, C-4315, Longshore, payee |
Payment Of Compensation Without Award |
U.S. Department of Labor |
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(Longshore and Harbor Workers' Compensation Act, |
Office of Workers' Compensation Programs |
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as extended) |
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OMB No. |
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NOTE: This Notice is to be filed with the District Director not later |
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FOR OFFICE USE |
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than the same day that first payment is made. A copy should |
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1. OWCP No. |
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2. CARRIER'S No. |
be sent to the payee(s) AND to their attorney (if represented). |
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3.Name of injured person (First, middle, last - please print or type)
4.Address of injured person (Number, street, city, state and ZIP code)
UNITED STATES
5. Date of accident or first illness (Month, day, year)
6. Date disability began (Month, day, year)
7. Name of injured, or dependents of injured, to whom compensation will be paid
8.
Average weekly wage $
multiplied by 2/3 compensation rate $
(Mark if maximum rate is being paid)
Yes
No
9. Compensation will be paid from - Enter month, day, year.
9a. For DBA cases only, is the employer continuing to pay the injured person's salary?
Yes |
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No |
until notice is given that payment has been stopped or suspended
I0. Date of first payment (Month, day, year.)
9b. If so, are these salary continuation payments being made in lieu of compensation payments?
Yes |
No |
11. Has medical care and treatment been provided by a physician or hospital chosen by the injured person?
(Mark appropriate box)
Yes
No
12. Name and address of employer (Name, number, street, city, state, ZIP code and country)
UNITED STATES
13. Name and address of insurance carrier and/or claim administrator(Name, number, street, city, state, ZIP code and country)
UNITED STATES
14. Authorized signature
15. Type or print title and name of person whose signature appears in item 14 |
Phone number |
16. Date
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 10 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 accordance with
20CFR 702.234. 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, Room C4315, 200 Constitution Avenue, NW, Room
DO NOT SEND COMPLETED FORMS TO THIS OFFICE.
Form
Rev. August 2011