U.S. Department of Labor 

July 1, 2003 

Employment Standards Administration 

Office of Workers· Compensation Programs 

Division of Longshore and 

Harbor Workers' Compensalion 

Washington, D.C. 20210 

File Number: 

Kotice 111 

KOTI CE TO INSURANCE CARRIERS UNDER THE LONGSHORE AND HARBOR 

WORKERS' COMPENSATIOK ACT AND EXTENSIONS 

SUBJECT: ANNUAL REPORT OF OUTSTANDING LIABILITIES FORM LS-274 

In connection with the pr~vilege to write workers' compensation 

insurance under Longshore and Harbor Workers' Compensation 

Act, and extensions, this Off requires certain authori 

insurance carriers to submit an annual report of outstanding 

workers' compensation liabil under the Act and its 

extensions, as of June 30 of each year. The report due no later 

than September l, 2003, should show the following information for 

each open case as of June 30, 2003: 

1. State the insurance carrier's name and address in the blocks 

provided on the report. This is needed for identification 

purposes. Do not omit this information. 

2. Furnish the authorization number of the insurance carrier 

following its name on the report. This information was given to 

the insurance carrier at the time the company was authorized to 

write Longshore Act coverage. 

3. Show the date of the report in the appropriate block. 

4. List the Social Security Number of each claimant in 

(a). The employer's or carrier's file number is no 

required. 

column 

longer 

5. List the OWCP case number for each open claim in column (b). 

Include in the report all controverted claims and cases paid by 

the Special Fund where the employer is still liable for any 

medical benefits and cases in excess insurance status. It is the 

responsibility of every reporting insurance carrier to record the 

OWCP case numbers of all of their claims and report those numbers 

on the LS-274. 

6. Give the date of injury for each open claim, in chronological 

order, for each July 1 through June 30 period in column (d). The 

dates of injury should correspond to the insurance carrier's 

period of authorization. 

7. Identify the nature of injury in column (e). Abbreviations 

for injury types may be used but an annotation of "occupational" 

or "traumatic", etc. is not acceptable. 

8. State the total amount of benefits paid for each reported 

claim in column (f). This means that compensation and 

medical benefits from the date of injury to the date of the 

report should be declared for each open case. 

Working for America's Workfon::e 
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9. Give an estimate of the total future compensation to be paid 

for each claim in column (g). This total amount should be based 

upon a worst case basis. It should not be reduced for 

expectations of reimbursement from a re-insurance carrier, an 

anticipated third party recovery, anticipated lump sum settlement 

or pending second injury fund authorization. Attorney fees and 

administrative expenses should not be included. 

10. Give an estimate of the total future medical benefits to be 

paid for each claim in column (h). The same method of reporting 

appl as mentioned in number 9. 

11. Add the amounts in columns (g) and (h) and declare it in 

column (i) . 

12. Subtotals of the estimated future payments in columns (g), 

(h) and (i) are to be provided for each July 1 to June 30 period. 

13. Identify third party claims in colur:m (j). 

14. Identify fatal cases column (k). 

15. Declare a grand total for columns (g), (h) and (i). 

16. Insurance Carriers with no open claims must still file Form 

LS-274. 

The report of outstanding liabilities may submitted on Form 

LS-274, Report of Injury Experience of Insurance Carriers (copy 

enclosed), or in a similar format that provides the same 

information. However, if the similar report does not furnish the 

same information as requested in the LS-274 then it is not 

acceptable. 

Insurers must provide separate reports for the Act and each of 

its extensions, (i.e., Longshore and Harbor Workers' Compensation 

Act, Outer Continental Shelf Lands Act, Defense Base Act, and 

Nonappropriated Fund Instrumentalities Act). Also, insurers with 

subsidiaries authorized under the Act must provide separate 

reports for each subsidiary. 

This insurance carrier's annual report of outstanding liabilit 

is due no later than September 1, 2003 and must include a 

separate notarized statement signed by a corporate officer 

attesting to the completeness and accuracy of the information 

provided. Officials of entities under the Nonappropriated Fund 

Instrumentalities Act should also submit notarized 

certifications. 

Certification of the Report of Outstanding Liabilities by other 

than corporate officers as stated above will not be accepted. 

The signed statement should be on a separate letterhead. Please 

indicate in your correspondence the name and telephone number 

the person to be contacted in the event there are any questions. 

A negative report (no open cases) must also be accompanied with 

the same separate notarized statement from a company official as 

mentioned earlier in t~is notice. 
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Failure to submit the complete report as outlined in this Notice 

may result in the termination of your authorization to write 

coverage under the Longshore Act and extensions. 

Your report should be as follows: 

U.S. Department Labor 

ESA/OWCP/DLHWC, Room C-4315 

200 Constitution Avenue, N.W. 

Attention: Mi Niss 

Washington, D.C. 20210 

This insurance carrier authorization cannot be transferred, and 

it cannot be assigned. Any change involving the corporate name, 

structure, ownership, organization, etc., may affect the 

insurance carrier's authority and must be brought to the 

attention of this Office prior to the effective date of the 

event. 

For further information you may contact Ms. Linda Myer at (202) 

693-0289. 

Michael Niss 

Director, Division of 

Longshore and Harbor 

Workers' Compensation 

Enclosure