U.S. Department of Labor 

December 15, 1982 

Employment Standwds Administration 

Ol!ice of Workers' CoMpensation Programs 

Division of Longshore and 

Harbor Workers' Compensation 

Washington, D.C. 2021 O 

No. 54 

ADM 8-5.3 

X COM-L 2 

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, 1982: Employer's Case Number, 

OWCP Case Number, Name of Injured Employee, Date of Injury, 

Nature of Injury, Amount of Compensation and Medical Benefits 

Paid through December 31, 1982, 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. The report of outstanding 

liabilities may be submitted on Form LS-274, Report of Injury 

Experience of Self-Insured Employer (copy attached). 

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, Nonappropriated Fund Instrumentalities 

Act, and District of Columbia Compensation Act*). Also, selfinsured 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. Please 

include applicable Department of Labor Authorization Number on 

each report submitted. 

All estimated future payments listed for each open claim are 

to be listed chronologically, by accident date, for each 

authorization year (July 1 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 Total" for all 

estimated future payments. Each self-insured employer's 

annual report of outstanding liabilities is due no later than 

March 1, 1983, 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. Certification of the Report of Outstanding Liabilities by other than 

the corporate officers stated above will not be accepted by 

this Office. 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 the event there are 

any questions. 

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

workers' compensation 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/OWCP/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. Frank Fiorini of this Office 

at (202) 523-8700 or 523-8721. 

---yt it lf!,rnl~ IJM~. MONTONE 

Associate Director, 

Longshore and Harbor 

Workers' Compensation 

Attachment 

*Note: Only open cases under the District of Columbia 

Compensation Act where the date of injury was prior to 

July 26, 1982 should be reported.