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U.S. DEPARTMENT OF LABOR 

EbCPLOYMBNT STANDARDS ADMINISTRATION 

Office of Workers' Compensation Programs Washington, D.C. 20211 

IMPORTANT 

September 26, 1975 No. 23 

NOTICE TO INSURANCE CARRIERS, SELF-INSURED EMPLOYERS 

UNDER THE LONGSHOREMEN'S AND HARBOR WORKERS' COMPENSATION 

ACT, AS EXTENDED, AND OTHER INTERESTED PERSONS 

Subject: Instructions for Use of Privacy Act Notice under the 

Longshoremen' s and Harbor. Workers' Compensation Act,.· 

As Extended 

The Department of Labor considers that all records created pursuant to the Longshoremen's and Harbor.Workers' Compensation 

Act (33 u.s.c. 901 et seq.), or one of its extensions (the 

District of Columbia Compensation Act, the Defense Base Act, 

the Outer Continental Shel_f Lands Act, and the Nonappropriated 

Fund Instrumentalities Act) are records of the Department of 

Labor. In keeping with its responsibility for administering 

these Acts, the Office of Workers' Compensation Programs (OWCP) 

has prepared the attached notice to claimants (Inst. LS-555) in 

accordance with the Privacy Act of 1974 (P.L. 93-579, 5 u.s.c. 

552a). 

The notice must be furnished to any person who is requested to 

provide personal data to the OWCP in connection with claims for 

benefits payable under the Longshoremen's and Harbor Workers' 

Compensation Act, as extended. 

Employers coming under the jurisdiction of one of the above Acts 

are required to furnish Form LS-201, Notice of Employee's Injury 

or Death, to claimants when injuries, occupational illnesses, or 

deaths are reported to them (refer to Notice to Industry No. 6, 

January 19, 1973). When Form LS-201 is given to an employee (or 

dependent in a death case) the LS-555 should be attached to the' 

form. 

Supplies of the attached notice (Inst. LS-555) should be furnished 

by carriers to all employers obtaining workers' compensation coverage under one of the indicated Acts, with appropriate instructions 

for use. Self-insured employers may reproduce their own supplies. 

The use of this notice is required under the provisions of the 

Privacy Act o~974 ~on and after September 27, 1975. 

-;.I~~, c)c-J(,, ~ HERBERT A. DOYLE, JR. 

Director, Office of Workers' 

Compensation Programs 

Attachment 
U.S. DEPARTMENT OF LABOR 

EMPLOYMENT STANDARDS ADMINISTRATION 

Office of Workers' Compensation Programs 

PRIVACY ACT OF 1974 NOTICE 

In accordance with the Privacy Act of 1974 (Public Law No. 

93-579, 5 U.S.C. 552af, you are hereby notified that: (1) 

The Longshoremen's and Harbor Workers' Compensation Act, as 

amended and extended . (33 U.S .c .. 901 et seq.) is administered 

·by the Office of Workers' Compensation Programs.of the U.S. 

Department of Labor. In accordance.with this responsibility, 

the Office receives and maintains pe;r:sonal · information on 

claimants and their ·immediate families." (2) The information 

will be used to determine eligibility for ~nd the amount of 

benefits payable under the Act. (3) The information may be 

used by other agencies or persons in handling matters relating, 

directly or indirectly, to the subject matter of the claim, so 

long as such agencies or persons have received the consent of 

the individual claimant, or have complied with the provisions 

of 20 CER 702. {4) Furnishing all requested information will 

facilitate the claims adjudication process, and the effects of 

not providing all or any part of the requested information may 

delay the process, or result in an unfavorable decision or a 

reduced level of benefits (disclosure of a social security 

number.is:voluntary, the failure to .disclose such number will 

.not. result .in ·the deli.ial .. of any right, benefit or privilege to 

which an individual may be entitled}. 

THIS NOTICE SHOULD BE RETAINED FOR YOUR INFORMATION 

Inst. LS-555 

Sept. 1975