The section adds the sentence “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”. The section also adds, “The following information is
provided in accordance with the Privacy Act of 1974, 5 USC 552a”. Prior forms
requested this information.

e The Public Burden Statement has been edited to delete the Privacy Act reference, which
has been moved to the Privacy Act Statement section on the Form. Reference to the
Paperwork Reduction Act of 1995 has been deleted, and reference to the OMB control
number has been deleted.

Any questions regarding this Industry Notice or the revised Longshore Form LS-208 (Notice of
Payments) should be directed to the DLHWC Branch of Policy, Regulations and Procedures,
Washington, DC.

Khe Ge

Director, Division of
Longshore and Harbor Workers’ Compensation


Office of Workers’ Compensation Programs
U. S. Department of Labor Dividen of Longshore ana

Harbor Workers’ Compensation
200 Constitution Avenue, Room C-4319
Washington, DC 20210

February 9, 2018
Industry Notice No. 165

TO: INSURANCE CARRIERS AND SELF-INSURED EMPLOYERS UNDER THE
LONGSHORE AND HARBOR WORKERS’ COMPENSATION ACT (LHWCA), AND ITS
EXTENSIONS, AND OTHER INTERESTED PERSONS

SUBJECT: Newly revised Form LS-208 (Notice of Payments) and the termination of Form
LS-206 (Payment of Compensation Without Award)

e Mandatory Longshore Form LS-208, Notice of Final Payment or Suspension of
Compensation Payments, has been revised and renamed to Notice of Payments.

e Mandatory Longshore Form LS-206, Payment of Compensation Without Award,
has been eliminated.

The newly revised Form LS-208 (Notice of Payments) incorporates relevant sections of the, now
obsolete, LS-206 to make one combined form. This revised form is now available on the Office
of Workers’ Compensation Programs (OWCP) Division of Longshore and Harbor Workers’
Compensation (DLHWC) website:

https://www.dol.gov/owcp/dihwc/isforms.htm.

The revised version of the Longshore Form LS-208 (Notice of Payments) should now be
used. All prior versions of the Longshore Form LS-206 and LS-208 are considered
obsolete.

Revised FORM LS-208 (Notice of Payments): https://www.dol.gov/owcp/dlhwe/Is-208.paf.

OWCP made changes to Longshore Form LS-208 to incorporate relevant sections of the now
obsolete Longshore Form LS-206, including reorganizing the report of payments made on
account of permanent disability (for non-schedule loss and schedule loss) to include
disfigurement, modifying the report of payments to allow the user to enter up to two (2) separate
disability types, adding instructions for the employer/insurance carrier, and modifying the
Privacy Act and Public Burden Statements. Specifically, the following changes have been
made:

The form is renamed “Notice of Payments”.
The instructions at the top of the Form have been updated to:

o Identify each of the Division of Longshore and Harbor Workers’ Compensation
(DLHWC) Acts covered by the Form; and

o Instruct the employer/insurance carrier that information collected on the Form will
be used to determine whether compensation payments were timely and properly
made.


Box 1 — This section has been changed to include the “Date of Accident/IIIness”, rather
than the prior wording requesting the “OWCP No.” which was moved to Box 3.

Box 3 — This box has been changed to request the “OWCP No.” Prior forms requested
this information.

Box 3(a) — This box has been deleted to remove the DLHWC’s Central Mail Receipt
address and the SEAPortal website that is provided in the instructions page.

Box 4 — This section has been changed to include the “Name of Injured Worker and
Claimant if other than the injured worker’, rather than the “Name of employer” which was
moved to Box 17. Prior forms requested this information.

Box 5 — This box has been changed to include the “Claimant’s Address”, rather than the
“Address of employer” which was moved to Box 17(a). Prior forms requested this
information.

Box 6 — This section has been changed to include the “Compensation Disability type”
rather than the “Date of Injury’. Prior forms requested this information.

Box 7 — This section has been changed to “Date employee first lost time (Month, day,
year)” rather than the prior wording, “Date employee first lost pay because of injury’ to
provide more clarity regarding the data that should be entered in this box. Prior forms
requested same information.

Box 7(a) — This box has been deleted to remove “Date first check issued”. (This
information is requested at Box 11 and includes a request for “Month, day, year”). Prior
forms requested this information.

Box 8 — This section has been changed to “Average Weekly Wage $” and
“Compensation Rate $” rather than the prior wording, “Date physician found employee
able to return to work” to delete reference to the treating physician. Prior forms
requested this information.

Box 9 — This section has been changed to “Payment Begin Date (Month, day, year)”
rather than the prior wording, “Date employee returned to work”. Prior forms requested
this information.

Box 10 - This section has been changed to “Employer continuing to pay the injured
person's salary” and “If so, are salary continuation payments made in lieu of
compensation payments”, rather than the prior wording, “Was compensation paid at the
maximum rate?” Prior LS-206 requested this information.

Box 11 — This section has been changed to “Date first check issued (Month, day, year)”
rather than the prior wording, “State reason or reasons for termination or suspension of
payments”. Prior forms requested this information

Box 12 — This section has been changed to “Type of Notice”, rather than the prior
wording, “Date last payment made”. (This information is requested at Box 14).

Box 13 — This section has been changed to “State reason for interim or final payment
notice” rather than the prior wording, “Date of this notice”. The wording has been
changed to emphasize interim payments, which is new to the Revised form LS-208, and
to provide more clarity to stakeholders to eliminate any confusion on whether to file the
form LS-208 or form LS-206.


Box 14 — This section has been changed to “Date last payment made”, rather than the
section reserved for “Payments Made on Account of Disability’ and made to Claimant's
and beneficiaries. This section has been moved to Box 15. Prior LS-208 requested this
information.

Box 15 — In addition to the changes noted above, this section has been modified to
include reorganizing the report of payments made on account of permanent disability (for
non-schedule loss and schedule loss) to include “disfigurement”, and modifies the report
of payments to allow the user to enter up to two (2) separate disability types by using
drop down boxes. Prior LS-208 requested this information.

Box 16 — In addition to the changes noted above, this section has been modified to
delete “disfigurement” and modifies the “Enter Other Payments” to include “Beneficiary
payments”, and the payee type, i.e. Widow, Child, Student, Other, via drop box. Prior
LS-208 requested this information.

Box 17 — This section has been changed to “Employer Name?” rather than the prior
wording, “Name of insurance carrier or self-insured employer and claim administrator”
which has moved to Box 18. Prior forms requested this information.

Box 17(a) — This section has been changed to “Employer Address” rather than the prior
wording, “Address and phone number of person whose name is shown in Box 18” which
has moved to Box 18(a). Prior forms requested this information.

Box 19 — This section has been changed to “Signature of person authorized to sign for
employer or carrier”, rather than the prior wording, “Name and Title of person whose
signature appears in Box 18” which has been deleted. Prior forms requested this
information.

Box 20 — This section has been added to include “Print name of authorized person” after
Box 19. Prior forms requested this information.

Box 21 — This section has been changed to “Date of notice”. (This information was
previously requested at Box 13 of the old Form). Prior forms requested this information.

The message, “Employee — Please Read Carefully’, has been edited and a reference to
Box 3(a) has been deleted. A reference to further instructions on the reverse side of the
Form has also been deleted. Prior LS-208 requested this information.

Instructions have been added to the backside of the Form addressed to the
Employer/Insurance Carrier referencing their responsibilities and obligations in timely
completing the Form, and in updating the Form anytime an interim change in benefit
payments is made. Language was added addressing interim payments and explaining
that a penalty could be assessed for failure to timely report payments.

Instructions to the injured worker, on the backside of the Form, have been made more
succinct.

Instructions on where to submit the completed form remains the same. Prior forms
requested this information.

The Privacy Act Statement has been edited to delete reference to the Code of Federal
Regulations at 20 C.F.R. § 702.235. This section also deletes the sentence “Failure to
disclose all requested information may delay the processing of the claim, the payment of
additional benefits, or may result in an unfavorable decision or reduced level of benefits’.