Payment Of Compensation Without Award U.S. Department of Labor

(Longshore and Harbor Workers' Compensation Act, Office of Workers' Compensation Programs

as extended)

Expires: 01-31-2018

NOTE: This Notice is to be filed with the District Director not later than the same day that first

payment is made. A copy should be sent to the payee(s) AND to their attorney (if represented).

3. Name of injured person (First, middle, last - please print or type)

4. Address of injured person (Include number, street, city, state and zip code. Add country if not United States.)

5. Date of accident or first illness (Month, day, year) 6. Date disability began (Month, day, year)

7. Name of injured, or dependents of injured, to whom compensation will be paid

8.

multiplied by 2/3 compensation rate $ Average weekly wage $

(Mark if maximum rate is being paid)

9b. Payment Begin Date (Month, day, year)

9a. Type of compensation paid.

I0. Date of first payment (Month, day, year)

11. Has medical care and treatment been provided by a physician or hospital chosen by the injured person?

(Mark appropriate box) Yes No

12. Name and address of employer (Include name, number, street, city, state and zip code. Add country if not United States.)

13. Name and address of insurance carrier and/or claim administrator (Include name, number, street, city, state and zip code. Add country 

 if not United States.)

14. Authorized signature

15. Type or print title and name of person whose signature appears in item 14 16. Date signed(mm-dd-yyyy)

Form LS-206

Rev. January 2015

1. OWCP No. 2. CARRIER'S No.

Yes No

Phone number

Public Burden Statement

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 optional, however furnishing the information is required in accordance with 

suggestions for reducing this burden, to the U.S. Department of Labor, 200 Constitution Avenue, NW, Room C-4319, 

Washington, D.C. 20210, and reference the OMB Control Number.

DO NOT SEND COMPLETED FORMS TO THIS OFFICE.

displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes per response,

20CFR 702.234. Send comments regarding the burden estimate or any other aspect of this collection of information, including 

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection 

9c. Is the employer continuing to pay the injured person's salary?

Yes No

9d. If so, are these salary continuation payments being made in

Yes No

lieu of compensation payments?

OMB No. 1240-0043
PRIVACY ACT STATEMENT 

The Privacy Act of 1974 as amended (5 U.S.C. 552a), section 901 of Title 33 to the US Code and 33 U.S.C. 914 (b) 

and (c) authorize collection of this information. The purpose of this information is to determine the payment status 

of a given case under the Longshore and Harbor Workers' Compensation Act (LHWCA). Completion of this form 

is not mandatory; however, furnishing the information is required in accordance with 20CFR 702.234. Additional 

disclosures of this information may be to: (1) the employer which employed the claimant at the time of injury, or to 

the insurance carrier or other entity which secured the employer's compensation liability. (2) physicians and other 

medical service providers for use in providing treatment or medical/vocational rehabilitation, making evaluations 

and for other purposes relating to the medical management of the claim. (3) the Department of Labor's Office of 

Administrative Law Judges (OALJ), or other person, board or organization, which is authorized or required to 

render decisions with respect to the claim or other matter arising in connection with the claim. (4) Federal, state and 

local agencies for law enforcement purposes, to obtain information relevant to a decision under the LHWCA 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. (5) Failure to disclose all requested 

information may delay the processing of the claim, the payment of benefits, or may result in an unfavorable 

decision or reduced level of benefits.