11. Has a compensation Order issued?

5. This Commutation is for: (select one)

U.S. Department of Labor Commutation Application Office of Workers' Compensation Programs

You must use this form to request approval of commutation of compensation under 33 U.S.C. 909(g) 

or 42 U.S.C. 1652. You must attach documentation supporting your request if you have not already 

submitted it.

OMB No.: 1240-0058 

Expires: 03/31/2026

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 to the OWCP/DFELHWC Central Mail Receipt site 

at the following address: 

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

DFELHWC 

400 West Bay Street, Suite 63A, Box 28 

Jacksonville, FL 32202

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

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

Permanent Partial Disability Permanent Total Disability Death Benefits

6. Country of Residence

7. Average Weekly Wage 8. Compensation Rate

9. Describe the nature of the incident (i.e, gunshot, IED) with documentation

10. Identify official confirmation of the nature of the incident

Yes No

12. Have stipulations been submitted confirming details of the incident?

Yes No

13. If you are an employer or insurance carrier, have you attached an interim LS-208 form documenting all payments made?

Yes No

14. On a death case, the following documentation must be attached or previously submitted: death certificate, marriage certificate, birth 

certificate for all dependent children, evidence of other dependents

15. Name and date of birth, initial compensation rate of each beneficiary

Form LS-6

Name Date of Birth Initial Compensation Rate

I certify that all of the information above and in the attachments is accurate. 

I also certify that I have served the form and attachments on all other parties and their representatives. 

16. Print Name 17. Signature 18. Date (Month, Day, Year)
Public Burden Statement

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 10 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 commutation of 

compensation by the Office of Workers’ Compensation Longshore Program under 33 U.S.C. 909(g) or 42 

U.S.C. 1652. 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-3524, Washington, D.C. 20210 and reference the OMB Control Number. 

Note: Please do not return the completed LS-6 to this address.

DO NOT SEND COMPLETED FORMS TO THIS OFFICE.

PRIVACY ACT STATEMENT

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) The information will be used to determine eligibility for commutation of 

benefits. (3) Use of this form is required to request approval of commutation of compensation 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 consideration of the application or result in denial of 

the application. (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.

Form LS-6 

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