U.S. Department of Labor 

January 21, 1981 

Employment Standards Administration 

Office of Workers' Compensation Programs 

Division of Longshore and 

Harbor Workers' Compensation 

Washington, D.C. 20210 

No. 45 

NOTICE TO INSURANCE CARRIERS, AND SELF-INSURED EMPLOYERS 

UNDER THE LONGSHOREMEN' S AND HARBOR WORKERS' COMPENSATION 

ACT (LHWCA), AS AMENDED 

Subject: Revised Form LS-221, Application for Lump 

Sum Award 

A copy of the recently revised Form LS-221, Application for 

Lump Sum Award, is enclosed. This form replaces Form LS-221, 

revised September 1974, and is used by claimants when applying 

to the Deputy Commissioner for a lump sum award under 

Section 14(j) of the Act. Previous editions of Form LS-221 

are obsolete and should be destroyed. 

Insurance carriers and self-insured employers may print their 

own supplies of this form, or obtain them from printing companies officially authorized to print forms used in the administration of the Longshore Act. Forms printed by carriers and 

employers for their own use must conform to the sample, in all 

respects, to be acceptable. 

Please arrange for distribution of this form to your local 

offices making payments under the Longshore Act, or any of its 

extensions. Field personnel may obtain sample copies from 

LHWC District Offices. 

·--74yt?,})l~ 

~{..A. MONTONE 

Associate Director, 

Longshore and Harbor 

Workers' Compensation 

Enclosure 
OMS ,Approval No. 044R-1581 

U.S. DEPARTMENT OF LABOR APPLICATION FOR LUMP SUM AWARD 

EMPLOYMENT STANDARDS ADMINISTRATION (Under ffle Longshoremen'• and Harbor Workers' OFFICE OF WORKERS' COMPENSATION PROGRAMS Compensotlon Act, as extended) 

INSTRUCTIONS: Complete this application in duplicate and deliver or mail both copies to the 1. OWCP Case Number 

Deputy Commissioner having jurisdiction over the claim. If the Deputy Commissioner approves the 

applicationz it will be forwarded to Washingtonz D.C. for consideration of the Secretary of Labor. 

[This application is authorized by law (33 U.S.C. 914(j)). J 2. Carrier's Number 

3. Name of injured or deceased employee 

lr:itial, Last) 

(First I Middle 4. Address (Number and street, city and state, ZIP) 

5. Name and address of employer 6. Name and address of insurance carrier 

7. Date of employee's injury (Afonth, day, yearj 8. Date of employee's death (Month, clay, year) 

APPLICATION FOR LUMP SUM AWARD UNDER SECTION 14ljl 

I have filed claim with the Deputy Commissioner for an awatd of compensation on account of the above iniurv or death. The claim 

has been allowed and the amount of said award is being paid in periodic instalfments in accordance with the provisions of the Act. The 

insurance carrier or my employer (if self-insured) is willing to make a tump sum payment to me. 

I request that I be allowed a lump sum payment in an amount equal to the present value of ,the unpaid balance of the award commuted, at 4 percent true discount compounded anually. 

I understand that the liability of the carrier or my employer for compensation or any part thereof, except medical earek would be dis~ 

charged by payment of such a lump sum. 

My reasons for wanting a lump sum payment are stated below. (Note: Give fall reasons as to what money will be used for, such as, 

"To start a business, in which 1 haaie the following experience , , . "or "To expand a business in which 1 am engaged, 0 or "1 am em~ 

ployed and desire the lump sum payment for a sound investment," Such reasons as 1'To pay my debts" or "Ta buy a house" are not 

sufficiently detailed to indicate that the applicant will be able to sustain himself/herself after receiving the lump sum1 and a lump sum 

would not be approved if this i.<, tire only reason given.) Continue statement on a separate sheet of this size. 

9. I am a citizen of the United States 110. I am a citizen of (Name of I 11. Date of birth (Mo., day, yr,) 

D Yes 0 No (If you check "No"1 answer item 10) 

country) I 

12. Full name of person making application (Type or print) 13. Address of applicant (Number, street, city, state 1 ZIP) 

14. Signature of applicant 15, Date of this application 

{,\fonth1 day, year) 

PRIVACY ACT OF 1974 NOTICE 

In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that: ( 1) The Long. 

shoremen•s and Harbor Workers• Compendtion Act, as: amended and extended (33 US.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 personaf information on claimants and their immediate families. (2) The informatton witl be used to determine eligiblHty 

for and the amount of benefits payable under the Act. (3) The information may be used by other agencies or persons in handHng 

matters relating, directly or indirectly. to the subject matter of the claim, so long as such agencies or persons have received the con- sent of the individual claimant, or have complied with the provisions of 20 CFR 702. (4) Furnishing all requested information will 

facilitate the claims adjudication processi and the effects of not providing alt 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 voluntaryi the fail- ure to disclose such number will not result in the denial of any right, benefit or privilege to which an individual may be entitled). 

-

Form LS-221 

Rev. Jan. 1980