Form Ls 210 PDF Details

In the realm of workplace injuries and occupational illnesses, prompt and accurate communication with the U.S. Department of Labor's Office of Workers' Compensation Programs (OWCP) plays a pivotal role in ensuring that injured employees receive the benefits and support they are entitled to. Integral to this process is the Employer's Supplementary Report, known as Form LS-210, a document that employers must file under specific circumstances to provide updates on an employee's injury or illness status. This form becomes necessary when the initial Report of Injury or Illness (Form LS-202) does not specify a return-to-work date or when there are subsequent periods of disability following an employee's return to the workforce. The LS-210 form comprehensively covers various critical aspects, from the initial and subsequent periods of disability to the medical attention received, while also capturing employer and insurance carrier details. Its meticulous completion helps the OWCP accurately determine an injured worker's entitlement to benefits, making it a cornerstone in the administration of workers' compensation claims. The significance of the LS-210 form extends beyond mere procedural compliance; it serves as a key instrument supporting the recovery and rights of workers under the OWCP's purview.

QuestionAnswer
Form NameForm Ls 210
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesLS-206, OWCP, Inclusive, LS-208

Form Preview Example

Employer's Supplementary Report of

U.S. Department of Labor

Accident or Occupational Illness

Office of Workers' Compensation Programs

 

Notice: This Report should be filed promptly with the District Director in every case in which (1) Form LS-202 does not show date injured employee returned to work, and (2) each time injured employee has returned to work and later becomes disabled for work (33 U.S.C.930(b) if the information is not already reported via Form LS-206 or LS-208. If the employee was disabled for work more than 3 days, compensation payments should be reported on Forms LS-206 and LS-208. Medical reports must be sent to the District Director promptly following first treatment and thereafter while treatment continues. Please type or print all information. (if additional space is needed, use back of form.)

The information will be used to determine entitlement to benefits.

OMB No. 1240-0003

For Office Use

1.OWCP No.

2.Carrier's No.

3. Name of injured employee (First, middle initial, last)

4. Date of accident (Month, day, year)

5. Address of injured employee (Number and Street, City, State, ZIP code)

6. Name and address of your insurance carrier

7.Initial Period of Disability (Use Inclusive Dates for a and b)

a. From (Month, day, year)

b. Through (Month, day, year)

c. Date returned to work (Month, day, year)

 

 

 

8.If this report covers a period of disability after the date shown in item 7c. state each subsequent period of disability. Use inclusive dates for a. and b.

a. From (Month, day, year)

b. Through (Month, day, year)

c. Date returned to work (Month, day, year)

9.Did employee receive medical attention?

a. Yes - Give dates, names and addresses of doctors and hospitals providing treatment.

b. No - Explain

10.

Was employee treated by his or her choice of physician?

11. Was form LS-1 given to employee when injury was reported to you?

 

Yes

No

Yes

No

 

 

 

 

12.

Name of employer (Firm Name)

13. Employer's address (Number and Street, City, State, ZIP code)

 

 

 

 

 

14.Signature of person authorized to sign for employer

15. Name, official title and phone number of person signing

16.Date of report

(month, day, year)

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. 930(b)). 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.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

Form LS-210

Rev. March 2014

How to Edit Form Ls 210 Online for Free

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Completing this document will require attention to detail. Make sure all required fields are completed accurately.

1. To start off, while filling in the LS-1, start in the section that includes the subsequent blanks:

Filling in part 1 in LS-202

2. The third step would be to fill in these particular fields: Did employee receive medical, Yes Give dates names and, No Explain, Was employee treated by his or, Was form LS given to employee, Yes, Yes, Name of employer, Employers address Number and, Signature of person authorized to, Name official title and phone, Date of report, for employer, month day year, and According to the Paperwork.

Was form LS given to employee, Did employee receive medical, and for employer of LS-202

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