Notice of Controversion of Right 

to Compensation

U.S. Department of Labor

Office of Workers' Compensation Programs 

Longshore and Harbor Workers' Compensation 

This report is required to obtain or retain benefits and is authorized by law and regulation (33 U.S.C. 914(d), (e); 20 C.F.R. §702.251). 

Failure to report when controverting right to compensation can result in liability for 10 percent additional compensation. 

OMB No. 1240-0042 

Instructions: This form may be used by the employer/carrier to controvert the right to compensation. 33 U.S.C. 

914(a) requires the employer to pay compensation promptly and without an award unless the right to such 

compensation is controverted by the filing of this form. Failure either to pay each installment of compensation, or 

controvert the right to such compensation, within fourteen days after it becomes due may result in liability for 

additional compensation equal to ten percent of each installment not paid when due (33 U.S.C. 914(d), (e)). If 

the right to compensation is controverted, this form should be submitted to the District Director through the 

OWCP/DLHWC Central Mail Receipt site or uploaded directly to the case file at: 

https://seaportal.dol.gov/portal/?program_name=LS, and the reasons for such controversion should be fully 

stated in item 12. A copy of the completed form must be mailed to the claimant and claimant's representative.

1. OWCP File No. 

2. Employer File No. 

3. Carrier File No. 

4. Claimant's Name and Address 

First Name

name:

line 1: line 2:

state:

country:

8. Claim Filed or Injury Reported Under (check one) 

LHWCA OCSLA

DCWCA NFIA

DBA

9. Nature of Injury or Occupational Disease 

11. Date of Employer's First Knowledge of Injury (Month, Day, Year) 

6. Employer's Name, Address and Phone Number

5. Employee's Name and Address if different from Claimant's 

7. Carrier's Name, Address and Phone Number 

10. Date of Injury (Month, Day, Year) 

12. Right to compensation is controverted for the following reason(s): 

14. Print Name and Phone Number 

15. Title 

13. Authorized Signature 

16. Date of this Notice (Month, Day, Year) 

Form LS-207 

zip: city:

M.I.

Rev. Aug. 2021

Last Name

zip:

zip: zip:

city:

city: city:

country: 

phone:

st:

st: st:

telephone:

country: 

As verified by the signature below, this form was mailed to the claimant and claimant's representative.

This is notice that the employer (or its insurance carrier) makes objection to your right to 

benefits under the workers' compensation Act indicated in item 8 of this form, for the injury or 

death identified in items 9 and 10. Item 12 gives the reasons for this objection. If you believe 

you are entitled to workers' compensation benefits under the LHWCA and its extensions, or 

disagree with the grounds stated, please inform your servicing district office, giving reasons 

for your belief. For further instructions, please see the reverse side of this form.

Explanation 

to 

 

Employee

country: 

telephone: telephone:

Expires: 08/31/2024

telephone:
INSTRUCTIONS TO INJURED WORKER AND BENEFICIARY

A claim may be filed within one year after the injury or death (33 U.S.C. 913(a)). If compensation has been paid 

without an award, a claim may be filed within one year after the last payment. Time for filing a claim does not 

begin to run until the employee or beneficiary knows, or should have known by the exercise of reasonable 

diligence, of the relationship between the employment and the injury. 

 

In cases involving occupational disease which does not immediately result in death or disability, a claim may 

be filed within two years after the employee or claimant becomes aware, or in the exercise of reasonable 

diligence or by reason of medical advice should have been aware, of the relationship between the 

employment, the disease, and the death or disability. 

 

To file a claim for compensation benefits, complete and sign Form LS-203, Employee's Claim for Compensation 

or Form LS-262, Claim for Death Benefits. The form can be obtained through the OWCP/DFELHWC website at: 

https://www.dol.gov/agencies/owcp/dlhwc/lsforms or by your servicing district office. The contact information 

is available on the OWCP/DFELHWC website at: https://www.dol.gov/agencies/owcp/dlhwc/lscontac. 

 

Please be sure to include the OWCP Case Number and mail this form to the OWCP/DFELHWC Central Mail 

Receipt site at the following address:

U. S. Department of Labor 

Office of Workers' Compensation Programs 

Division of Federal Employees', Longshore and Harbor Workers' Compensation 

400 West Bay Street, Suite 63A, Box 28 

Jacksonville, FL 32202

Or upload the claim directly to the case file using the Secure Electronic Access Portal (SEAPortal).

Access the SEAPortal directly at: https://seaportal.dol.gov/portal/?program_name=LS

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. §522a) and the Paperwork Reduction Act of 1995, as 

amended. The authority for requesting the following information is 20 C.F.R. §702.251. Use of this form is optional, however furnishing the 

information is required in order to obtain and/or retain benefits. According to the Paperwork Reduction Act of 1995, an agency may not conduct or 

sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB 

control number for this information collection is 1240-0042. The time required to complete this information collection is estimated to average 15 

minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 

and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of 

information, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Longshore and Harbor Worker's 

Compensation, Room S-3229, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

DO NOT SEND COMPLETED FORMS TO THIS OFFICE. 

PRIVACY ACT STATEMENT

Privacy Act of 1974 as amended (5 U.S.C. §552a), section §914(d) of Title 33 to the U.S. Code and 20 C.F.R. §702.251 authorizes collection of 

this information. The purpose of this information is to inform the claimant of the reason(s) the insurance carrier or self-insured employer makes 

objection to paying compensation or medical benefits and to determine eligibility for the amount of benefits payable under the Longshore and 

Harbor Workers' Compensation Act and its extensions (LHWCA). Completion of this form is not mandatory; however, failure to provide the 

information may result in additional compensation benefits payable by the employer (33 U.S.C. §914 (e)). Additional disclosures of this information 

may be to: (1) The claimant and/or his representative. (2) The employer which employed the claimant at the time of injury, or to the insurance 

carrier or other entity which secured the employer's compensation liability. (3) Physicians and other medical service providers for use in providing 

treatment or medical/vocational rehabilitation, making evaluations and for other purposes relating to the management of the claim. (4) 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. (5) 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 and have been paid 

properly, and where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by law. (6) Failure to 

disclose all requested information may delay the processing of the claim, the payment of additional benefits, or may result in an unfavorable 

decision or reduced level of benefits.

PUBLIC BURDEN STATEMENT

Rev. Aug. 2021

Form LS-207