11. Check Issues Requiring Intervention and attach position paper with supporting documents:

5. Type of Intervention Requested (OWCP reserves the right to make a final determination)

U.S. Department of Labor 

Office of Workers' Compensation Programs

Request for Intervention

You must use this form to request intervention from the Office of Workers' Compensation Longshore 

Program. The District Suboffice has discretion on what action to take based on the request and 

documentation in the file. You must send a copy of the completed form to all parties and their 

representatives.

OMB No.: 1240-0058 

Expires: 03/31/2026

Or upload directly to the case file using the 

Secure Electronic Access Portal (SEAPortal) 

 

Access the SEAPortal directly at: 

https://seaportal.dol.gov/portal/

Submit form to the OWCP/DFELHWC Central Mail Receipt site 

at the following address: 

U.S. Department of Labor, Office of Workers' Compensation Programs 

DFELHWC 

400 West Bay Street, Suite 63A, Box 28 

Jacksonville, FL 32202

1. Date of Accident/Illness: 2. Carrier's No. 3. OWCP No.

4. Name of Injured Worker and Claimant if other than injured worker

Non-Conference Informal Conference

6. Employer 7. Insurance Carrier

8. Name, Address and Phone Number of Party Requesting Intervention

9. Briefly state the facts of the claim:

10. List the issues the parties have reached agreement on:

Occurrence of Injury

Responsible Employer/Carrier 

Jurisdiction/Situs/Status

Average Weekly Wage

Additional Compensation

Temporary Disability 

Permanent Disability

Medical

Special Fund Modification

Other

12. Describe efforts made to resolve issue(s):

As verified by the signature below, this form was sent to all opposing parties and their representatives

13. Print Name 14. Signature 15. Date (Month, Day, Year)

Form LS-7 
Form LS-7 

Page 2

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 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 required to request intervention by the Office of Workers’ Compensation Longshore Program. 

See 20 C.F.R. 702.301, 702.311. 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-3524, Washington, D.C. 20210 and reference the OMB Control Number. Note: 

Please do not return the completed LS-7 to this address.

Public Burden Statement

DO NOT SEND COMPLETED FORMS TO THIS OFFICE.

PRIVACY ACT STATEMENT

The following information is provided in accordance with the Privacy Act of 1974, as amended, 5 USC 552a. (1) This 

collection of information is authorized under the Longshore and Harbor Workers’ Compensation Act (LHWCA) and its 

extensions. (2) The information collected, which includes a list of disputed issues between the parties to the 

compensation claim, will be used to determine whether and what level of intervention by the Office of Workers’ 

Compensation Longshore Program would help resolve the disputed issues. (3) Completion of this form is required to 

request intervention by the Office of Workers’ Compensation Longshore Program. (4) Disclosures of this information 

may be made to: the claimant and his or her representative(s); the employer, the insurance carrier or other entity 

that secured the employer’s compensation liability, and their representative(s); any other entity that may be liable for 

the payment of compensation; the Department of Labor’s Office of Administrative Law Judges (OALJ), or other 

person, board or organization, authorized or required to render decisions on claims or other matters arising in 

connection with a claim; Federal, state and local agencies to determine whether benefits are being and have been 

paid properly and, where appropriate, to pursue salary/administrative offset and debt collection actions required or 

permitted by law; and other individuals, their representatives, and government agencies enforcing a legal obligation 

for alimony or child support. (5) Failure to provide the information on this form may delay processing of the claim, 

the payment of benefits, or may result in an unfavorable decision or reduced level of benefits. (6) This information is 

included in two Systems of Records, DOL/OWCP-3, 4, published at 81 Federal Register 25765, 25859-61 (April 29, 

2016), or as updated and republished.