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REQUIREMENTS FOR AUTHORIZATION TO BE SELF‐INSURED UNDER THE

LONGSHORE AND HARBOR WORKERS’ COMPENSATION ACT

AND/OR EXTENSIONS

The following information and instructions pertain to the requirements for authorization to

become self‐insured under the Longshore and Harbor Workers’ Compensation Act and

extentions, Defense Base Act, Nonappropriated Fund Instrumentalities Act and Outer

Continental Shelf Lands Act.

ATTACHMENT:

Form LS‐271, Application for Self‐Insurance

INFORMATION AND MATERIAL WHICH MUST BE SUBMITTED:

1) Completed Form LS‐271, Application for Self‐Insurance.  A separate application must

be completed under each Act for each separately incorporated subsidiary.  A parent

company must guarantee the obligations of each subsidiary.  The guaranty must be

submitted on parent company letterhead.

2) Certified audited financial statements for the most recent three years.

3) Loss information under the Act for the most recent five years, showing loss

information for each year, including total incurred, paid and outstanding losses.

4) Information pertaining to specific excess insurance.  The net retention and

maximum limit should be shown, and a specimen copy of the policy should be

included.

5) Statement showing amount of annual payroll under the Act by insurance

classification code.

6) Statement pertaining to the proposed administration of claims.  If claims are to be

self‐administered, a statement should be submitted showing the qualifications of

those individuals who will process claims.  If a self‐insurance service organization is

to be used, a profile of the organization should be submitted, showing the

experience of claims handling personnel managing cases under the Act.

7) Employer Identification Number (EIN) for each applicant company.  This can be

furnished in item 2 of the application.
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8) A  certification by a corporate officer on company letterhead stating that the

applicant company will perform the following:

a. Comply with all statutory and regulatory obligations, including meeting  timeliness

for paying benefits and reporting information [Section 14(a) – (i)];

b. Utilize the informal dispute resolution mechanisms in good faith by bringing only

issues that are ready for resolution (i.e. all documentation is available) and sending

representatives who are both prepared to and have authority to resolve issues;

c. Participate and cooperate with all efforts by professional and trade associations to

self‐police industry compliance;

d. Monitor and be held responsible for the performance in numbers 1‐2 above of their

Third Party Administrator (TPA) or other claims handlers; and

e. Respond to all penalty assessments in a timely manner.

There is no filing fee or other cost associated with filing an application for self‐insurance

authorization.  You should allow about 30 to 60 days for processing upon receipt of a

completed application.   

If a third party is filing on behalf of a client company then the application should contain the

name of the responsible person and the address of the client company to whom notification of

the decision should be sent.  If all correspondence is to be sent to the third party, the

application should so indicate.    

The completed application form and all related material should be submitted to:  

U.S. Department of Labor  

OWCP/DFELHWC, Room S-3229

200 Constitution Avenue, N.W.

Washington, D.C.   20210

Questions relating to self‐insurance should be addressed to the Longshore Insurance Branch

at the same address.  The telephone number is (202) 354-9624.

Director

Division of Federal Employees’,

Longshore and Harbor Workers' Compensation

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PLEASE TYPE THIS STATEMENT ON PARENT COMPANY LETTERHEAD 

PARENT COMPANY GUARANTY 

Guaranty made on (date) by (parent company) of (address) as 

guarantor of all obligations incurred by (subsidiary company) of 

(address) under the Longshore and Harbor Workers' Compensation 

Act and/or its extensions, the Outer Continental Shelf Lands Act; 

the Defense Base Act and the Nonappropriated Fund 

Instrumentalities Act.

In consideration of the granting of self-insurance authority

under the Longshore and Harbor Workers' Compensation Act and/or 

its extensions, the Outer Continental Shelf Lands Act; the 

Defense Base Act and the Nonappropriated Fund Instrumentalities 

Act to (subsidiary company), (parent company) unequivocally 

guarantees the payment of all obligations incurred by (subsidiary 

company) under the Longshore and Harbor Workers' Compensation Act 

and/or its extensions, the Outer Continental Shelf Lands Act; the 

Defense Base Act and the Nonappropriated Fund Instrumentalities 

Act. This guaranty is absolute and unconditional and continuous 

except as specifically provided below. 

(Parent company) may revoke this guaranty, effective on the last 

day of any annual period of authorization or reauthorization by 

the Secretary of Labor or designee of (subsidiary company) to act 

as a self-insurer under the Longshore and Harbor Workers' 

Compensation Act and/or its extensions, by giving notice to the 

Division of Longshore and Harbor Workers' Compensation by 

registered mail not less than 60 days prior to the effective date 

of such revocation; provided, that any such revocation shall not 

affect (parent company's) continuing obligation to guarantee all 

obligations of (subsidiary company) whenever accruing, for which 

(subsidiary company) is liable under the Longshore and Harbor 

Workers' Compensation Act and/or its extensions, the Outer 

Continental Shelf Lands Act; the Defense Base Act and the 

Nonappropriated Fund Instrumentalities Act, on the basis of its 

conduct of employment during the period this guaranty was in 

effect.

I, being the duly elected and acting Secretary of (parent 

company) do hereby certify that the foregoing was duly adopted by 

the Board of Directors of (parent company) at a meeting thereof 

duly called and held on (date), at which a quorum was present and 

acting throughout, and that said guaranty is in full force and 

effect.

_______________________

___________________ Signature

Corporate Seal 

_______________________

Typed Name and Title 

___________________

Notary Seal _______________________

Date