U.S. Department of Labor 

November 24, l981 

ADM 8-5.3 

X COM-L 2 

Employment Standards Administration · 

Office of Workers' Compensation Programs 

Division of Longshore and 

Harbor Workers' Compensation 

Washington, D.C. 20210 · 

N_o. 52 

NOTICE TO SELF-INSURED EMPLOYERS UNDER THE LONGSHOREMEN'S 

AND HARBOR WORKERS' COMPENSATION ACT, AS AMENDED 

Subject: Annual Report, ,of Outstanding Liabilities 

In connection with the privilege of self-insuring workers' 

compensation liabilities under the Longshoremen's and Harbor 

Workers' Compensation Act, and extensions, this Office 

requires each authorized self-insured employer to submit an 

annual report of outstanding workers' compensation liabilities 

under the Act, to include the following information for each 

open case existing as of December .31, 1981: Employer's Case 

Number, ONCP Case Number, Name of Injured Employee, Date of 

Injury, Nature of Injury, Amount of Compensation and Medical 

Benefits Paid through December 31, i981, Estimate of Future 

Compensation Benefits Payments, Estimate of Future Medical 

Benefits Payments, and Estimate of Total Future Compensation 

Payments. Fatal cases are to be separately identified. ~he 

report of .. outstanding liabilities may be submitted on Form 

LS-274,.Report of.Injury Experience of Self-Insured Employer 

(copy enclosedl. 

Self-insured employers must provide separate reports for the 

Act and each of its extensions {i.e., Longshoremen's and 

Harbor Workers' Compensation Act, Outer Continental Shelf 

Lands Act, Defense Base Act, District of Columbia Compensation 

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 

self-insured employer or subsidiary has more than one location, 

a separate report must be submitted for each location. 

All estimated future payments listed for each open claim are 

to be listed chronologically, by accident date, for each 

authorization year {July l through June 30). Subtotals of the 

estimated future payments requested in the first paragraph 

above or as called for in columns {g), (h), and (i) of Form 

LS-274 are to be provided for each authorization year. 
2 -

Finally, each report should reflect a "Grand Tota.1" for a11 

estimated future payments. · Each self-insured employer's 

annual report of outstanding liabilities is due no later than · March l, 1982, and must include a separate notarized statement 

signed by the-corporation treasurer or other appropriate 

.corporate officer (President, Vice President, Secretary or 

Controller) of the self-insured employer attesting to the 

completeness and accuracy of the information provided. The 

signed statement should,be on a separate form or letter. 

Please indicate in your correspondence the name and telephone 

number of· the person ·to contact in_ t:he _ event the:r:e are any 

questions. · 

In the event that a -self-insured employer has no outstanding 

workers' compensatiqn liabilities under the Act, a negative 

report should be filed for each location of the company and 

each subsidiary. The certification and due date requirements 

are the same as outlined above. 

In order to insure that your report is received in-this Office 

as expeditiously as possible, it should be addressed as follows: 

U.S. Department of Labor 

Attention: Neil A. Montone 

ESA/0WCP/DLHWC, Room C4315 

200 Constitution Avenue, N.W. 

Washington,· D_~'C. - 20210 

Failure to submit the -completed report and/or reports as outlined 

in this notice could result'in the termination of your authorization to self-insure. Your-cooperation in providing the ·report 

as requested will be appreciated. · 

For further information contact Mr. Prank Fiorini -of this 

Office at (202) 523-8700. 

~f-~ 

Associate Director, 

Longshore and Harbor 

Workers' Compensation 

Enclosure