8. Settlement Amount for Compensation 

(Provide the Case # and Amount for 

Each Case – up to 4 cases)

13. Have the Parties considered Medicare Secondary Payer Act?

10. Are there any liens? If so, signature(s) are required from lien holder(s)

U.S. Department of Labor 

Office of Workers' Compensation Programs

Settlement Approval Request Section 8(i)

OMB No.: 1240-0058 

Expires: 03/31/2026

You must use this form to request approval of a settlement under Section 8(i) of the Longshore and 

Harbor Worker's Compensation Act and its Extensions. You must attach a fully executed 8(i) 

settlement agreement.

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 and attachments to the OWCP/DLHWC Central Mail 

Receipt site by certified mail with return receipt requested or commercial 

delivery service with tracking capability at the following address: 

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

Division of Longshore and Harbor Workers' Compensation 

400 West Bay Street, Suite 63A, Box 28 

Jacksonville, FL 32202

You must include the following in the 8(i) settlement agreement: Brief summary of facts; Issues in dispute; Claimant's current work 

status; Medical reports describing injuries, impairment, and date of maximum medical improvement; Anticipated future medical 

treatment, the costs thereof, and medical paid in the last three years; Collateral sources for future medical treatment, if medical 

benefits are being settled; Explanation of why the settlement is adequate and not signed under duress; and Signatures of all parties. 

The application must be self-sufficient when read on its own without any background information. See 20 C.F.R 702.242, 702.243.

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

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

5. Claimant's Telephone Number (required if claimant is not represented by an attorney)

6. Average Weekly Wage 7. Compensation Rate

Yes No

11a. Are Attorney Fees resolved (itemized fee petition must be attached) Yes No

11b. If yes, amount agreed upon

12. Total Amount Due to Claimant if Approved:

Yes No

Form LS-8

9. Settlement Amount for 

Medical Treatment 

(Provide the Case # and Amount for 

Each Case – up to 4 cases)
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 20 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 approval of a settlement by the Office of Workers’ Compensation Longshore Division 

under 33 U.S.C. 908(i) and 20 C.F.R. 702.241-702.243. 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-3229, Washington, D.C. 20210 and reference the OMB Control Number. Note: 

Please do not return the completed LS-8 to this address.

DO NOT SEND COMPLETED FORMS TO THIS OFFICE.

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) This information will be used to determine the adequacy of settlements agreed to under the LHWCA. 

(3) Completion of this form is required to request approval of a settlement 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); 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 settlement request, 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.

Public Burden Statement

PRIVACY ACT STATEMENT

Form LS-8 

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