Name of Injured/Deceased 

Employee: OWCP No:

WAIVER OF SERVICE BY REGISTERED OR CERTIFIED MAIL 

FOR EMPLOYERS AND/OR INSURANCE CARRIERS

Longshore and Harbor Workers' Compensation Act,

As Extended (see instructions on reverse)

U.S. Department of Labor

Office of Workers' Compensation Programs

www.dol.gov/owcp/dlhwc/index.htm

2. OMB No: 1240-0053

NEW Waiver Exp. Date: 06/30/2025

REVOKE prior Waiver

CHANGE information on prior Waiver

Party or Representative Agreeing to Service of Compensation Order(s) by email (check one):

Employer

Employer's Representative

Insurance Carrier

Insurance Carrier's Representative

I, , acting on behalf of , waive the 

company's statutory and/or regulatory right to be served with the compensation order(s) in this case by registered or certified mail. I 

instead request and consent for the company to be served with the compensation order(s) in this case by email. I agree that service of 

the compensation order(s) by email satisfies all service requirements imposed by 33 U.S.C. § 919(e) and 20 C.F.R. § 702.349.

I affirm that I have the authority to execute this waiver on behalf of . I also affirm that the 

information provided below is correct and accurate. If the District Director is unable to accomplish service of the compensation order(s) 

by email (i.e. if the email bounces back as undeliverable), I understand and agree that the compensation order(s) will be served on the 

company by registered or certified mail.

Signature: Date:

Name:

Title:

Firm or Business Name (if applicable):

Address: Telephone Number:

EMAIL ADDRESSES: No more than two (2) email addresses can be listed per party.

Name:

Line1:

Line2:

City:

St.: Zip:

Country:

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 5 minutes per response, for locating the 

form on the internet, completing the information required and either mailing or uploading the form via secure portal. Use of this form is optional. 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.

Form LS-801

March 2015

1.

3.

4.

5.

6.

7.

8.
Information for Employers and Insurance Carriers (LS-801)

Under the Longshore and Harbor Worker's Compensation Act (LHWCA), parties and their representatives have 

a statutory and/or regulatory right to be served with compensation orders by registered or certified mail. See 33 

U.S.C. § 919(e) and 20 C.F.R. § 702.349.

To expedite delivery, the Office of Worker's Compensation Programs (OWCP) will email compensation orders 

instead of mailing them by registered or certified mail to individuals who have submitted a "Waiver of Service 

by Registered or Certified Mail." (Waiver)

Waivers are case specific, and no other form/request/letter may be used to request a waiver.

Instructions for Completion of Form LS-801

Complete the waiver by completing each field on the waiver. Type or print clearly.

1) Provide the injured worker's name and OWCP case number.

2) Check whether this is a new waiver, a revocation of a prior waiver or a change to a prior waiver (e.g. an 

 email address has changed).

3) Identify your role in the claims process as the Employer, the Employer's Representative, the Insurance 

 Carrier or the Insurance Carrier's Representative. A separate waiver must be submitted for each party 

 or representative electing service by email.

4) Provide your full name, title (if applicable), the name of your firm or business name, the address and the 

 phone number.

5) Provide a valid email address to which the order should be sent. No more than two (2) email addresses 

 can be listed per party.

This form must then be signed and dated and submitted to the OWCP/DLHWC.

a. DLHWC's Secure Electronic Access Portal (SEAPortal) may be used to electronically upload the waiver

 form into the case file. The SEAPortal can be accessed at the following web address:

https://seaportal.dol-esa.gov

b. If mailing the form, it should be sent to the DLHWC Central Mail Receipt site at the following address:

U.S. Department of Labor

OWCP/DLHWC

400 West Bay Street, Suite 63A, Box 28

Jacksonville, FL 32202

Warning - Your signature on the Waiver serves as a knowing and voluntary waiver of your right to 

receive the compensation order(s) by registered or certified mail. If you choose to receive service 

via email, a hard copy of the order will not be sent to you via mail.

PRIVACY ACT STATEMENT

The Privacy Act of 1974 as amended (5 U.S.C. 552a), section 919(e) of Title 33 to the US Code and 20 C.F.R. §702.349 authorizes collection of this information. 

The purpose of this information is to inform the District Director that the employer/insurance carrier and/or its authorized representative are waiving service of 

compensation orders by registered or certified mail and designating e-mail instead under the Longshore and Harbor Workers' Compensation Act (LHWCA). 

Completion of this form is not mandatory. Additional disclosures of this information may be to: (1) The claimant and/or his representative. (2) 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. (3) 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. (4) 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 and have been paid properly, and where appropriate, to pursue 

salary/administrative offset and debt collection actions required or permitted by law. (5) Failure to disclose all requested information may delay the processing of 

the claim, the payment of additional benefits, or may result in the payment of additional benefits.

Form LS-801

March 2015

NOTICE

If you have a substantially limiting physical or mental impairment, Federal disability non-discrimination law gives you the right to receive help from OWCP in the 

form of communication assistance, accommodation and modification. Please contact our office for information about the kinds of help available, such as 

alternate document formats.