U.S. Department of Labor Employment Standards Administration 

Office of Workers' Compensation Programs 

Division of Longshore and 

July 1, 2003 Harbor Workers' Compensation 

Washington, O.C. 20210 

File Number: 

Notice 110 

NOTICE TO SELF-INSURED EMPLOYERS UNDER THE LONGSHORE AND HARBOR 

WORKERS' COMPENSATION ACT AND EXTENSIONS 

SUBJECT: ANNUAL REPORT OF OUTSTANDING LIABILITIES FORM LS-274 

As part of the privilege of self-insuring workers' compensation 

liabilities under the Longshore and Harbor Workers' Compensation 

Act, and extensions, this Office requires each authorized finsurer to submit an annual report of outstanding workers' 

compensation liabilities under the Acts, as of June 30 of 

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 employer's name and address 

on the report. This is needed for identi 

not omit this information. 

the blocks provided 

ion purposes. Do 

2. Furnish the authorization number of the self-insured employer 

following its name on report. This information was given to 

the employer at the time the company was authorized to self 

insure. 

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

4. List the Social Security Number of each claimant in column 

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

required. 

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

Include in the report 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 self-insurer 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 l through June 30 period in column (d). The 

dates of injury should correspond to the employer's period of 

self-insurance 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. not acceptable. 

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

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

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

report should be declared for each open case. 

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 an excess insurance carrier, 

Wbrking for America :S llbrlcfon:-e 
2 

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 applies 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 l to June 30 period. 

13. Identify third party claims in column (j). 

14. Identify fatal cases in column (k). 

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

16. Self-insured employers with no open claims must still file 

Form LS-274. 

The report of outstanding liabilities may be submitted on Form 

LS-274, Report of ury Experience of Self-Insured Employer 

(copy enclosed), or a similar format that provides the same 

information. However, the similar report does not furnish the 

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

acceptable. 

Self-insured employers 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, 

self-insured employers with subsidiaries authorized under the Act 

must provide separate reports for each subsidiary. If a selfinsured employer or subsidiary has more than one location, a 

separate report must be submitted for each location. 

This self-insured employer's annual report of outstanding 

liabilities is due no later than September l, 2003 and must 

include a separate notarized statement signed by a corporate 

officer attesting to the completeness and accuracy 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 of 

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 this notice. 

Failure to submit the complete report as outlined in this Notice 

may result in the termination of your authorization to selfinsure (20 CFR 703.312). 
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Your report should be addressed as follows: 

U.S. Department of Labor 

ESA/OWCP/DLHWC, Room C-4315 

200 Constitution Avenue, N.W. 

Attention: Michael Niss 

Washington, D.C. 20210. 

This self-insurance authorization cannot be transferred, and it 

cannot be assigned. Any change involving the corporate name, 

structure, ownership, organization, etc., may affect the selfinsurance 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 Mr. Peter La Lena at 

(202) 693-0910. 

Michael Niss 

Director, Division of 

Longshore and Harbor 

Workers' Compensation 

Enclosure 
Report of Injury Experience of 

Self-Insured Employer 

U.S. Department of Labor 

Employment Standards Administration 

Office of Workers' Compensation Programs 

Division of Longshore and Harbor workers' Compensation 

This report is to be used to list all open cases as of the date of the report. The information provided will be used to determine the adequacy of a self-insurer's security 0MB No.: 1215-0160 

deposit. Submission of the information is mandatory (20 CFR 703.310). Persons are not required to respond to this collecticn of information unless it displays a currently 

valid 0MB control number. 

Employer's Name Employer's Address (Number and street, city, state and Z'P code) Reporting List All Open Cases Date of Report 

Period as of the Date of 

.. This Report 

Estimate of Estimate of Estimate of Check 

X~l(,l(,lfl( 01 Nature of Injury Future Com- Fu!ure Medi- Total Future Third Check 

XQ41,tl)llr,¢;~$!> OWCP Case (Use abbreviations - Amount of pensation cal Payments Compensation Party Fatal 

~IJll'l!'J< Number Name of Injured Employee Date or Injury frx, spr, etc.) B8nefits Paid Payments (Disability cases Payments cases Cases 

SSN only) (g + h) ,,, ,,, 

(a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) 

I 

Public Burden Statement · 

We estimate that it will take an average of 60 minutes to complete this collection of information, including time for i'eviewing instructions, searching existing data sources, gathering and 

maintaining the data needed, and completing and reviewing the collection of information_ If you have any comments regarding these estimates or any other aspect of this collection of 

information, including suggestions for reducing this burden, send them to the U.S. Department of Labor, Division of Longshore and Harbor Workers' Compensation, Room C4315, 200 

Constitution Avenue, N.W., Washington, D.C. 20210. 

OWCP 

Verification 

(Leave 

Blank) 

(I) 

Form LS-274 

Rev. May 1998