U.S. Department of Labor

Office of Workers' Compensation Programs

Employee's Claim for Compensation

See Instructions On Reverse OMB No.1240-0014

3. Name of person making claim (Type or print)

First MI. Last

5. Claimant's address (number, street, city, state, ZIP code, country)

6. Marital Status

10. Did injury cause loss of time beyond day

or shift of accident?

7. Do you think of yourself as: 8. Date of Birth 9. Social Security # (Required

Yes No

17. Has 3rd party or other claim been made

because of this Injury?

b. Total earnings during year immediately

before injury. 16. Wages or earnings when injured a. Weekly

(include overtime allowances, etc.) Yes No

19. Number of days usually

worked per week

18. Number of years you worked 20. Name of supervisor at time of accident?

for this employer

21. Earliest date supervisor or employer knew of accident 22. Were you employed elsewhere during the week injured?

No Yes (If "Yes," state where and when on reverse.)

23. Exact place where accident occurred (Street address, city, town, country) (For Longshore also include: name of vessel, pier, terminal, etc.)

24. Describe in full how the accident occurred (Relate the events which resulted in the injury or occupational disease. Tell what the injured was

doing at the time of the accident. Tell what happened and how it happened. Name any objects or substances involved and tell how they

were involved. Give full details on all factors which led or contributed to the accident. If more space is needed, continue on reverse.)

25. Nature of injury (name part of body affected - fractured 

left leg, bruised right thumb, etc. If there was a loss or 

 loss of use of a part of the body. describe.)

26. Have you received medical attention for this injury?

(if *Yes," give name and address of doctor, clinic, hospital, etc.)

Yes No

28. Was such treatment provided by employer? 29. Are you still disabled on account of this injury?

Yes No Yes No

35. Address of employer (Number, street, city, state, ZIP code, country) 36. If accident occurred outside the U.S.,

state whether you are a U.S. Citizen

Yes No

37. I hereby make claim for compensation benefits, 38. Date of this claim

Signature of claimant

or person acting on their behalf

Section 31(a)(1) of the Longshore Act. 33 U.S.C. 931(a)(1) provides. as follows: Any claimant or representative of a claimant who knowingly and 

willfully makes a false statement or representation for the purpose of obtaining a benefit or payment under this Act shall be guilty of a felony, and on 

conviction thereof shall be punished by a fine not to exceed $10,000, by imprisonment not to exceed five years, or by both.

Form LS-203

Rev. Nov 2023

Married Single

line1:

line2:

(mm/dd/yyyy) (hh:mm am/pm)

(mm/dd/yyyy) (hh:mm am/pm)

(mm/dd/yyyy)

(mm/dd/yyyy)

1. OWCP No.

4. Date of Injury

11. Date and time of accident. 11a. Did you stop work immediately?

Yes No

12. Date and hour pay stopped?

13. Date and hour you returned to work 14. Occupation (Job title: longshore worker, welder, etc.) 

Yes No

(if "No," explain in Item 24)

27. Were you treated by a physician of

your choice?

Yes No

30. Have you worked during the period

of disability? Yes No

31. Have you received any wages since becoming disabled?

Yes No (if "Yes," give dates on reverse)

32. Has injury resulted in permanent disability, amputation or serious

disfigurement?

Yes (Describe on reverse.) No

33. Name of employer (individual or firm name) 34. Nature of employer's business

2. Carrier's No.

15. Injured while doing regular work?

monetary and medical, under the

Telephone No.

city:

state:

country:

zip code:

by law)

9a. Nationality

(mm/dd/yyyy) (hh:mm am/pm)

Expires: 11/30/2026

Transgender man Transgender woman

Male

Genderqueer/ 

Decline to answer

Female

Another gender

gender nonconforming/non-

(For DBA also include: name of the DOD facility or associated worksite - i.e. base, FOB, camp, etc.)

binary

country:

state: zip code:

city:

line2:

line1:
Instructions

• Use this form to file a claim under any one of the following laws:

Longshore and Harbor Workers' Compensation Act

Defense Base Act

Outer Continental Shelf Lands Act

Nonappropriated Fund Instrumentalities Act

- Applicant may leave items 1. and 2. blank. 

Except as noted below, 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. The 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. Persons are not

required to respond to this collection of information unless it displays a currently valid OMB control number. The information will be used to determine

an injured worker's entitlement to compensation and medical benefits.

In case of hearing loss, a claim may be filed within one year after receipt by an employee of an audiogram, with the accompanying report thereon, 

indicating that the employee has suffered a loss of hearing.

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 this form.

Use the space below to continue answers. Please number each answer to correspond to the number of the item being continued.

Privacy Act Notice

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a) you are hereby notified that (1) the Longshore and Harbor Workers' Compensation 

Act, as amended and extended (33 U.S.C. 901 et seq.) (LHWCA) is administered by the Office of Workers' Compensation Programs of the U.S. Department 

of Labor, which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to 

determine eligibility for and the amount of benefits payable under the LHWCA. (3) Information may be given to 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. (4) Information may be given to physicians 

and other medical service providers for use in providing treatment or medical/vocational rehabilitation, making evaluations and for other purposes relating to 

the medical management of the claim. (5) Information may be given to 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. 

(6) Information may be given to the 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 or have been paid properly, and where appropriate, to pursue salary/administrative offset and debt 

collection actions required or permitted by law. (7) Disclosure of the claimant's Social Security Number (SSN) or tax identifying number (TIN) on this form is 

mandatory. The SSN and/or TIN and other information maintained by the Office may be used for identification, and for other purposes authorized by law. (8) 

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

reduced level of benefits.

Public Burden Statement

Note: The notice applies to all forms requesting information that you might receive from the Office in connection with the processing 

and/or adjudication of the claim you filed under the LHWCA and related statutes.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid 

OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing 

instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Use of 

this form is optional, however furnishing the information is required in order to obtain and/or retain benefits. ( 33 U.S.C.913(a) ). Send comments regarding the 

burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, 200 

Constitution Avenue, NW, Room S-3524, Washington, D.C. 20210, and reference the OMB Control Number.

If you have already been assigned an OWCP Case Number, please include your OWCP case number and submit electronically to the file through the 

DFELHWC’s Secure Electronic Access Portal (SEAPortal) (preferred method) https://seaportal.dol.gov/portal/. Alternatively, to submit the claim by mail, 

please be sure to include your case number and mail to the Central Mail Receipt site at the address shown below. 

If this is a new claim, and you do not have an OWCP Case Number, please submit the form through the SEAPortal (preferred method) at 

https://seaportal.dol.gov/portal/ in the "Submit New Claim or Report of Injury" section. Or to the Case Create Fax Number (202) 513-6814. Alternatively, to 

submit the "case create" form by mail, please send it to the address below: 

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

Form LS-203 

Rev. Nov 2023 

Page 2