Employer's First Report of Injury U.S. Department of Labor

(See instructions on reverse) Office of Workers' Compensation Programs

OMB No. 1240-0003

1. OWCP No. 2. Carrier's No. 3. Date and Time of Accident

(mm/dd/yyyy) (hh:mm am/pm)

4. Name of injured/deceased employee (Type or print - first, M.I., last) 5. Employee's address (No., street, city, state, ZIP, country)

6. Injury is reported under the following 7. Indicate where injury occurred 9. Date of birth

Act (Mark one)

8. Sex

(Longshore Act only) (Mark one)

M F Longshore and Harbor Workers' A A Aboard vessel or over 10. Social security no. (Required Compensation Act navigable waters

B Pier/Wharf

D Defense Base Act

C Dry dock

Nonappropriated Fund Instru- B

D Marine terminal

mentalities Act

E Building way

Outer Continental Shelf Lands

F

C

Marine railway

Act

G Other adjoining area

16. Was employee doing usual work when

injured/killed? (if no, explain in Item 26)

14. Did employee stop work

immediately?

Yes 15. Date & hour empl returned to work Yes

No No

20. Date and hour pay stopped

23. Wages or earnings (include

overtime, allowances, etc.)

25. How was knowledge of accident or

occupational illness gained? 24. Exact place where accident occurred including city, state 

and country if outside U.S. This item should specify area if 

accident was in maritime employment and occurred in area 

adjoining navigable waters.

26. Describe in full how the accident occurred (Relate the events which resulted in the injury or occupational disease. Tell what the injured was doing at the time of the accident. Tell what happened and how it happened. Name any objects or substances involved and tell

how they were involved. Give full details on all factors which led or contributed to the accident.)

27. Nature of Injury (Name part of body affected - fractured left leg, bruised right thumb, etc.) If there was amputation of a member of the body, describe.

28a. Has medical attention 29. Enter date of 

been authorized?

30. Was first treating 31. Has insurance Yes Yes Yes physician chosen carrier been

No by employee? No notified? No

33. Hospital

34. Insurance

35. Employer

36. Employer's 37. Signature of person authorized to sign for employer Phone number

38. Official title and phone number of person signing this report 39. Date of this report 

(mm/dd/yyyy)

Form LS-202

Rev. Nov 2020

First Name M.I. Last Name Telephone

(Mark (X) days)

32. Physician

Carrier

Business

Street:

City: St: Zip: Ctry:

(mm/dd/yyyy)

(mm/dd/yyyy) (hh:mm am/pm)

(mm/dd/yyyy) (hh:mm am/pm)

(mm/dd/yyyy) (hh:mm am/pm) (hh:mm am/pm) (mm/dd/yyyy)

authorization.

Name of person signing this report

11. Did injury cause death?

No Yes - If yes, skip to 16

12. Did injury cause loss of time beyond Yes

day or shift of accident?

No

13. Date and hour employee Date Time

first lost time

because of injury

a. Hourly

b. Daily

c. Weekly

d. Yearly

Name of: Address - Enter number, street, city, state, zip code

S M T W T F S

17. Did injury/death occur on

employer's premises?

18. Dept. in which employee normally works(ed) 19. Occupation Yes

No

21. Which days usually worked per week? 22. Date employer or foreman first knew of accident.

1. Contracting Agency

2. Prime Contract #

28b. LS-1 issued?

Yes No

or Occupational Illness

3. Sub-Contract #

by law)

10a. Nationality (DBA only)

Expires: 2/29/2024
This report is required by 33 U.S.C. 930(a) and must be filed with the U.S. Department of Labor, Office of Workers' Compensation 

Programs, Division of Longshore and Harbor Workers’ Compensation by electronic submission via OWCP web portal, facsimile or Central 

Mail Receipt Site. File form within 10 days from the date of injury or death or from the date the employer first has knowledge of an injury 

or death. Under the law all medical treatment and compensation must be furnished by the employer or its insurance company. Treatment 

must be by a physician chosen by the employee, unless the physician is on a list of physicians currently not authorized by the 

Department of Labor to render medical care under the Act. Compensation payments become due and are payable on the 14th day after the 

employer first has knowledge of the injury or death. Penalties may be charged for failure to comply with provisions of the law. The 

information will be used to determine entitlement to benefits. Persons are not required to respond to this collection of information unless 

it displays a currently valid OMB control number. For further information, visit our website at

https://www.dol.gov/agencies/owcp/dlhwc/lscontac

B. Nonappropriated Fund Instrumentalities Act covers

employees of nonappropriated fund instrumentalities of the

Armed forces, e.g., post exchanges, motion picture service,

etc. 

C. Outer Continental Shelf Lands Act covers employees of

private employers engaged in operations conducted on the 

Outer Continental Shelf for the purpose of exploring for,

developing, removing, or transporting by pipeline the natural

resources of submerged lands.

NOTE: FILING THIS FORM DOES NOT CONSTITUTE AN ADMISSION OF LIABILITY UNDER THE COMPENSATION ACT. Any employer, insurance 

carrier, or self-insured employer who knowingly and willfully fails to submit this report when required or knowingly or willfully makes a false 

statement or misrepresentation in this report shall be subject to a civil penalty based on amounts outlined in the Federal Civil Penalties Inflation 

Adjustment Act Improvements Act of 2015, for each such failure, refusal, false statement, or misrepresentation. [33 U.S.C.930(e)] This report 

shall not be evidence of any fact stated herein in any proceeding in respect to any such injury or death on account of which the report is made. 

[33 U.S.C. 930(c)] 

REPORTABLE INJURY – Any accidental injury which causes loss of one or more shifts of work or death allegedly arising out of and in the course of 

employment, including any occupational disease or infection believed or alleged to have arisen naturally out of such employment, or as a natural or 

unavoidable result from an accidental injury. If the employer controverts the right to compensation it must also file a notice of controversion with the 

District Director within 14 days after it has knowledge of the allged injury or death.

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 reporting burden for this collection of information is estimated to average 15 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. Completion of this form is mandatory. 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, N.W., Room S-3229, Washington, DC 20210. 

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE

Item 6 – A. Longshore and Harbor Workers’ Compensation Act

covers employees injured while engaged in maritime

employment upon the navigable waters of the United States 

(including any adjoining pier, wharf, dry dock, terminal,

building way, marine railway, or other adjoining area

customarily used by an employer in loading, unloading,

repairing, or building a vessel); - employees injured upon the

navigable waters of the United States and other described

areas who at the time of injury were engaged in maritime

employment and are not otherwise specifically excluded under

the Act (33 U.S.C. 902).

D. Defense Base Act covers any employment (1) at military,

air, and naval bases acquired by the United States from foreign

countries; (2) on lands occupied or used by the United States

for military or naval purposes outside the continental limits of 

the United States; (3) upon any public work in any Territory or

possession outside the continental United States under a

contract of a contractor with the United States; (4) under a

contract entered into with the United States where such

contract is to be performed outside the continental United

States and at places not within the areas described in (1), (2), 

and (3) above for the purpose of engaging in public work; (5)

under certain contracts approved and financed by the United 

States under the Mutual Security Act of 1954, as amended; and

(6) in the service of American employers providing welfare or

similar services for the benefit of the Armed Forces outside the

Continental United States. 

Item 24 – “Exact place where accident occurred” requires the 

nearest street address, city and town. In addition - 

If on a vessel,

Give place on vessel where injury happened (Deck, hold,

tweendeck, engine room, etc.) Name of vessel

If either on an adjoining pier, wharf, dry dock, terminal

building way, marine railway, or other area customarily

used in loading, unloading, repairing, or building a 

vessel

Name or number of pier, dry dock, marine railway, etc. 

Name of the terminal or shipyard

Nearest street address – City and State

If injury or death is reported under the Defense Base

occured.

If on the Outer Continental Shelf,

Give drilling site and block number

Area name (e.g. West Delta Area)

Federal Lease Number, State Lease Number

Distance from and name of nearest land,

name of State

l

l

l

l

Act, give the name of the country where injury or death

Form LS-202

Rev. Nov 2020

PRIVACY ACT OF 1974 NOTICE

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a) you are hereby notified that (1) the Longshore and Harbor Workers' 

Compensation Act, as amended and extended (33 U.S.C. 901 et seq.) (LHWCA) is administered by the Office of Workers' Compensation Programs of the 

U.S. Department of Labor, which receives and maintains personal information on claimants. (2) Information which the Office has will be used to determine 

eligibility for the amount of benefits payable under the LHWCA. (3) Information may be given to the claimant or his/her representative. (4) Information may 

be given to 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. (5) Information may be given to 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. (6) Information may be given to 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 or have been paid properly, and, where appropriate, to pursue 

salary/administrative offset and debt collection actions required or permitted by law.

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