Ls202 Form PDF Details

When an injury or illness occurs in the workplace, navigating the aftermath and ensuring the injured party receives the appropriate care and compensation can be complex. Among the critical first steps an employer must take is filling out the LS-202 Form, also known as the Employer's First Report of Injury or Occupational Illness. This form plays a pivotal role in the workers' compensation process and is overseen by the U.S. Department of Labor's Office of Workers' Compensation Programs. It is designed to record essential details about the incident, including the time and place of the injury or illness, the affected employee's personal details, and the nature of the injury or illness. The reporting is mandatory under several acts, including the Longshore and Harbor Workers’ Compensation Act, depending on the nature and location of employment. Its completion ensures that the process for determining benefits can commence promptly. Completing and submitting this form within the stipulated timeframe is not only a requirement but a crucial step in facilitating a fair and expedient workers' compensation claim process. It is also worth noting that failure to accurately complete the form or meet the reporting deadlines can lead to penalties. Thus, the LS-202 form is a fundamental document that sets the stage for the workers' compensation process, helping to protect the rights and welfare of employees who suffer from work-related injuries or illnesses.

QuestionAnswer
Form NameLs202 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesls 202 fillable form, ls202 form, 202 report, how to ls202

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Employer's First Report of Injury

 

U.S. Department of Labor

or Occupational Illness

 

Office of Workers' Compensation Programs

 

(See instructions on reverse)

 

 

 

OMB No. 1240-0003

 

 

Expires: 2/29/2024

1. OWCP No.

2. Carrier's No.

3. Date and Time of Accident

 

 

 

(mm/dd/yyyy) (hh:mm am/pm)

4. Name of injured/deceased employee (Type or print - first, M.I., last)

First Name

M.I. Last Name

Telephone

5. Employee's address (No., street, city, state, ZIP, country)

Street:

City:St: Zip:Ctry:

6. Injury is reported under the following

 

7. Indicate where injury occurred

8. Sex

 

 

 

9. Date of birth

 

Act (Mark one)

 

 

 

(Longshore Act only) (Mark one)

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

Longshore and Harbor Workers'

 

 

 

 

M

F

 

 

 

 

 

A

 

 

Aboard vessel or over

 

 

 

 

 

 

 

 

Compensation Act

 

 

A

10. Social security no. (Required

 

10a. Nationality (DBA only)

 

 

 

navigable waters

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

Nonappropriated Fund Instru-

 

 

 

 

by law)

 

 

 

 

 

 

 

mentalities Act

 

 

B

Pier/Wharf

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

Outer Continental Shelf Lands

 

C

Dry dock

11. Did injury cause death?

 

 

 

 

 

Act

 

 

 

No

 

Yes - If yes, skip to 16

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D

Defense Base Act

 

 

D

Marine terminal

 

 

 

 

 

 

 

 

 

 

12. Did injury cause loss of time beyond

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Contracting Agency

 

 

E

Building way

day or shift of accident?

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

Marine railway

 

 

 

 

 

 

 

 

2. Prime Contract #

 

 

13. Date and hour employee

Date

Time

 

 

 

 

 

 

 

 

 

 

G

Other adjoining area

first lost time

(mm/dd/yyyy)

(hh:mm am/pm)

3. Sub-Contract #

 

 

 

because of injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. Did employee stop work

Yes

15. Date & hour empl returned to work

16. Was employee doing usual work when

Yes

immediately?

 

 

(mm/dd/yyyy)

(hh:mm am/pm)

injured/killed? (if no, explain in Item 26)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

17. Did injury/death occur on

Yes

18. Dept. in which employee normally works(ed)

 

19. Occupation

 

 

 

employer's premises?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. Date and hour pay stopped

21. Which days usually worked per week?

 

22. Date employer or foreman first knew of accident.

(mm/dd/yyyy)

(hh:mm am/pm)

(Mark (X) days)

S

M T W T

F S

(mm/dd/yyyy)

(hh:mm am/pm)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23. Wages or earnings (include

24. Exact place where accident occurred including city, state

25. How was knowledge of accident or

overtime, allowances, etc.)

and country if outside U.S. This item should specify area if

occupational illness gained?

 

 

 

 

 

 

accident was in maritime employment and occurred in area

 

 

 

 

 

 

 

a. Hourly

 

 

 

 

 

 

 

 

 

 

 

adjoining navigable waters.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.Daily

c.Weekly

d.Yearly

26.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.)

27.Nature of Injury (Name part of body affected - fractured left leg, bruised right thumb, etc.) If there was amputation of a member of the body, describe.

28a. Has medical attention

Yes

been authorized?

No

 

28b. LS-1 issued?

Yes No

29.Enter date of authorization.

30. Was first treating

Yes

physician chosen

No

by employee?

31. Has insurance

Yes

carrier been

 

notified?

No

Name of:

Address - Enter number, street, city, state, zip code

32.

Physician

 

 

 

 

 

 

33.

Hospital

 

 

 

 

 

 

 

34.

Insurance

 

 

 

 

Carrier

 

 

 

35. Employer

 

 

 

 

 

 

 

36.

Employer's

37. Signature of person authorized to sign for employer Phone number

 

 

Business

 

 

 

 

 

 

 

38.

Official title and phone number of person signing this report

Name of person signing this report

39. Date of this report

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

Form LS-202

 

 

 

 

Rev. Nov 2020

This report is required by 33 U.S.C. 930(a) and must be filed with the U.S. Department of Labor, Office of Workers' Compensation Programs, Division of Longshore and Harbor Workers’ Compensation by electronic submission via OWCP web portal, facsimile or Central Mail Receipt Site. File form within 10 days from the date of injury or death or from the date the employer first has knowledge of an injury or death. Under the law all medical treatment and compensation must be furnished by the employer or its insurance company. Treatment must be by a physician chosen by the employee, unless the physician is on a list of physicians currently not authorized by the Department of Labor to render medical care under the Act. Compensation payments become due and are payable on the 14th day after the employer first has knowledge of the injury or death. Penalties may be charged for failure to comply with provisions of the law. The information will be used to determine entitlement to benefits. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. For further information, visit our website at https://www.dol.gov/agencies/owcp/dlhwc/lscontac

REPORTABLE INJURY – Any accidental injury which causes loss of one or more shifts of work or death allegedly arising out of and in the course of employment, including any occupational disease or infection believed or alleged to have arisen naturally out of such employment, or as a natural or unavoidable result from an accidental injury. If the employer controverts the right to compensation it must also file a notice of controversion with the District Director within 14 days after it has knowledge of the allged injury or death.

Item 6 – A. Longshore and Harbor Workers’ Compensation Act covers employees injured while engaged in maritime employment upon the navigable waters of the United States (including any adjoining pier, wharf, dry dock, terminal, building way, marine railway, or other adjoining area customarily used by an employer in loading, unloading, repairing, or building a vessel); - employees injured upon the navigable waters of the United States and other described areas who at the time of injury were engaged in maritime employment and are not otherwise specifically excluded under the Act (33 U.S.C. 902).

B.Nonappropriated Fund Instrumentalities Act covers employees of nonappropriated fund instrumentalities of the Armed forces, e.g., post exchanges, motion picture service, etc.

C.Outer Continental Shelf Lands Act covers employees of private employers engaged in operations conducted on the Outer Continental Shelf for the purpose of exploring for, developing, removing, or transporting by pipeline the natural resources of submerged lands.

Item 24 – “Exact place where accident occurred” requires the nearest street address, city and town. In addition -

lIf on a vessel,

Give place on vessel where injury happened (Deck, hold, tweendeck, engine room, etc.) Name of vessel

lIf either on an adjoining pier, wharf, dry dock, terminal building way, marine railway, or other area customarily used in loading, unloading, repairing, or building a vessel

Name or number of pier, dry dock, marine railway, etc. Name of the terminal or shipyard

Nearest street address – City and State

lIf injury or death is reported under the Defense Base Act, give the name of the country where injury or death occured.

D.

Defense

Base

Act covers any employment (1) at military,

l

If on the Outer Continental Shelf,

air, and naval bases acquired by the United States from foreign

 

 

countries; (2)

on lands occupied or used by the United States

 

Give drilling site and block number

for

military or

naval

purposes outside

the continental limits of

 

 

Area name (e.g. West Delta Area)

the United States;

(3) upon any public work in any Territory or

 

 

Federal Lease Number, State Lease Number

possession

outside

the

continental

United States under a

 

 

Distance from and name of nearest land,

contract

of

a

contractor

with

the

United

States; (4) under a

 

 

name of State

contract

entered

into with

the

United

States where such

 

 

 

contract

is

to be

performed outside the continental United

 

 

States and at places not within the areas described in (1), (2),

 

 

and

(3)

above for

the purpose of engaging in public work; (5)

 

 

under certain

contracts approved

and financed by the United

 

 

States under the Mutual Security Act of 1954, as amended; and

 

 

(6)in the service of American employers providing welfare or similar services for the benefit of the Armed Forces outside the Continental United States.

PRIVACY ACT OF 1974 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. (2) Information which the Office has will be used to determine eligibility for the amount of benefits payable under the LHWCA. (3) Information may be given to the claimant or his/her representative. (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 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.

NOTE: FILING THIS FORM DOES NOT CONSTITUTE AN ADMISSION OF LIABILITY UNDER THE COMPENSATION ACT. Any employer, insurance carrier, or self-insured employer who knowingly and willfully fails to submit this report when required or knowingly or willfully makes a false statement or misrepresentation in this report shall be subject to a civil penalty based on amounts outlined in the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015, for each such failure, refusal, false statement, or misrepresentation. [33 U.S.C.930(e)] This report shall not be evidence of any fact stated herein in any proceeding in respect to any such injury or death on account of which the report is made. [33 U.S.C. 930(c)]

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. Completion of this form is mandatory. 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, N.W., Room S-3229, Washington, DC 20210.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE

 

Form LS-202

Page 2

Rev. Nov 2020

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How one can fill out ls 202 portion 1

2. Now that the previous part is complete, it's time to include the necessary details in Date and hour pay stopped, Which days usually worked per week, mmddyyyy, hhmm ampm, Mark X days, S M T W T, Date employer or foreman first, mmddyyyy, hhmm ampm, Wages or earnings include, a Hourly, b Daily c Weekly, d Yearly, Exact place where accident, and How was knowledge of accident or in order to move forward to the next part.

Tips on how to fill in ls 202 portion 2

3. In this step, examine Employers, Business, Signature of person authorized to, Official title and phone number, Name of person signing this report, Date of this report mmddyyyy, and Form LS Rev Nov. Each of these are required to be filled out with greatest precision.

ls 202 conclusion process shown (portion 3)

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