U.S. Department of Labor 

January 29, 2002 

Employment Standards Administration 

Office of Workers' Compensation Programs 

Division of Longshore and 

Harbor Wori<ers' Compensation 

Washington, D.C, 2021 O 

File Number: 

NOTICE TO INSUF1\NCE CARRIERS AND SELF-INSURED EMPLOYERS 

LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT AND DISTRICT 

OF COLUMBIA (DC) COMPENSATION ACT 

SUBJECT: 2002 Advance Assessment for the Special Fund pursuant 

to Section 44 of the Longshore Act 

Section 44 of the Longshore and Harbor Workers' Compensation Act 

provides for an annual assessment of each authorized insurance 

carrier and self insurer for payment into the Special Fund, to 

provide for payments described under Section 44(i). Separate 

accounts are maintained for the District of Colu:robia (DC) Act and 

the Longshore Act and its extensions. Separate instructions 

apply for reporting payments under the DC Act and the Longshore 

Act and its extensions (Defense Base Act, Outer Continental Shelf 

Lands Act and Nonappropriated Fund Instrumentalities Act). 

PLEASE READ ALL NOTICES CAREFULLY. 

FORM LS-513, REPORT OF PAYMENTS - LONGSHORE 

This notice transmits Form LS-513, Report of Payments, and the 

instructions for completion and return of this form. This 

report, along with your share of the Special Fund's costs during 

calendar year 2001 under Section 8(f), will serve as the basis 

for determining the final amount of your company's 2002 

assessment. Please make sure that the report is correct in 

accordance with the instructions provided. 

FOR.~ LS-513, REPORT OF PAYMENTS - DC 

This notice transmits Form LS-513, Report of Payments, and 

instructions for completion and return of the form. This report, 

along with your share of the total compensation and medical 

payments reported during calendar year 2001 will serve as the 

basis for determining the final amount of your company's 2002 DC 

assessment. Please report only compensation and medical payments 

where the date of injury was prior to July 26, 1982 under the 

DCCA Act and make certain that the report is correct in 

accordance with the instructions provided. 

Working for America's Workfoire 
(2) 

ADVANCE ASSESSMENT (LONGSHORE) 

This notice also transmits your Longshore Act advance assessment 

billing, calculated using your reported compensation payment 

figure for calendar year 2000, the total of all compensation 

payments reported for calendar year 2000, (the data 

available at this time), plus CY 2001 Section 8(f) costs, the 

total of all CY 2001 Section 8(f) costs, and the estimated CY 

2002 Longshore Act Special Fund expenditures. amount due for 

your CY 2002 advance assessment is shown at the bottom of the 

billing form. 

ADVANCE ASSESSMENT (DC ONLY) 

This notice also transmits your District of ColUc'llbia Compensation 

Act advance assessment billing, calculated using your reported 

compensation and medical payments for calendar year 2000, and the 

total of all compensation and medical payments reported for 

calendar year 2000 (the only data available at this time), and 

the estimated CY 2002 District of Columbia Special Fund 

expenditures. 

Please DO NOT combine any payments, pay each bill with a separate 

check,and forward the bi11 and check to this address: 

DEPAR~MENT OF LABOR - LONGSHORE 

P.O. BOX 371088M 

PITTSBJRGH, PA 15251 

Please send the completed LS-513, Report of Payments to this 

office at: 

U.S. Department of Labor 

200 Constitution Ave. N.W. 

Room C4315 - Longshore 

Washington D.C. 20210 

All payments and documents must be submitted no later than 

February 28, 2002. For any questions pertaining to this year's 

advance assessment please contact Carl Abildso at {202) 693-0801 

or ~2~80 ___ · __ 

MICHAEL NISS 

Director, Division of Longshore and Harbor 

Workers' Compensation 
( 3 ) 

INSTRUCTIONS FOR SUBMITTING FORM LS-513, REPORT OF PAYMENTS, FOR 

DETERMINATION OF ASSESSMENT UNDER THE LONGSHORE AND HARBOR 

WORKERS' COMPENSATION ACT, AND EXTENSIONS. 

GENERAL - Pursuant to Section 44 of the Longshore and Harbor 

Workers' Compensation Act, all authorized insurance carriers and 

self-insured employers under the Longshore Act and extensions, 

including the District of Columbia Compensation Act, are required 

each year to complete and file with the Office of Workers' 

Compensation Programs the attached Form LS-513. The form must be 

completed to show the number of cases and all compensation and 

medical payments made under the Act(s) during calendar year 2001. 

NOTE: A detailed listing must be submitted with the LS-513 

supporting the figures and it must contain the following: 

(l)Claimants Name (2)OWCP File Number (3)Social Security Number 

(4)Date of Injury (5)Indemnity/Medical paid in CY 2001. 

This report must be mailed to the Washington D.C. address (on 

page #2) and should not be sent to the post office box. This 

report may also be submitted in an electronic version. 

* DEFINITION OF WHAT MUST BE REPORTED ON FORM LS-513 

- All categories of compensation (i.e. TTD, TPD, PPD, PTD) paid 

during calendar year 2001 and reportable on an LS-208 must be 

reported on the LS-513. Compensation is considered paid when a 

check is issued and not when the check is cashed. 

- Attorney's fees assessed against the employer/carrier are NOT 

considered compensation; however, attorney's fees which are a 

lien on compensation are reportable. 

- All penalties and interest payable to the claimant ARE 

considered compensation and therefore reportable. 

- Section S(i) settlements, (including annuities) are fully 

reportable as compensation and/or medical in the year paid. 

Reimbursement to employer/carriers on cases where Section 

S(f)relief is ultimately granted are NOT to be deducted from 

total payments. 

Medical payments should include impartial medical 

ordered by OWCP but paid by the employer/carrier. 

report medical payments on no lost time cases. 

examinations 

Do not 

- Third party recoveries may NOT be deducted from payments. 
( 4) 

- Compensation may NOT be reduced or credited due to subsequent 

events, reversal on appeal, or credit under a State Act. 

Under the DISTRICT OF COLUMBIA COMPENSATION ACT only 

compensation and medical payments made during calendar year 2001 

where the injury date is prior to 7/26/82 should be reported. 

Payments under the Defense Base Act, for which reimbursement is 

expected under the War Hazards Compensation Act, should NOT be 

reported even though a claim for reimbursement has not yet been 

made. 

All payments for reimbursement from an excess/reinsurance 

Carrier or a national/state assigned risk pool MUS'I' BE REPORTED 

by the primary employer/carrier. 

- Any payments made directly to claimants by an excess or 

reinsurance carrier MUST BE REPORTED by the primary 

employer/carrier. 

- Any payments made under a so-called "deductible" policy 

provision are reportable by the insurance carrier that issued the 

policy. 

REQUIREMENT FOR CERTIFICATION OF LS-513 

Form LS 513, Report of Payments, must be r~•rt·ified as to the 

accuracy of the information submitted. This certification must 

be signed by an independent certified publ accountant. The 

certification must conform to the attached format (Attachment 

#1). The certifying individual cannot be: (1) an employee of the 

company submitting the Form LS-513; (2) any subsidiary or 

affil of that company; (3) anyone liated with an 

organization who provides claims services to a self insured 

employer. The certification must be submitted on the letterhead 

of the individual or firm performing the audit. 

The certification need not accompany the 

It must however be submitted no later then 

certification during each company's annual 

EXEMPTIONS 

of Form LS-513. 

12/31/02 to allow for 

financial audit. 

The fication requirement applies to all Forms LS-513, except 

the following: 

(1) Forms LS-513 showing compensation payments less then 

$200,000 which need only be signed on the reverse of the form. 

(2) Forms LS-513 submitted by self-insured nonappropriated fund 

instrumentalities need not be certified, other than by an 

off on the reverse of Form LS-
( 5) 

Attachment #1 

(Letterhead) 

We have audited the compensation and medical payments (as defined 

in the Longshore and Harbor Workers' Compensation 

Act, and extensions) included on the accompanying Form LS-513, 

Report of Payments, of __________ Company for the year 

ended December 31, 2001. Form LS-513 is prepared for the purpose 

of complying with the Longshore and Harbor Workers' Compensation 

Act (the "Act") and is the responsibility of the Company's 

management. Our responsibility is to express an opinion on Form 

LS-513 based on our audit. 

We conducted our audit in accordance with generally accepted 

auditing standards. Those standards require that we plan and 

perform the audit to obtain reasonable assurance about whether 

Form LS-513 is free of material misstatement. An audit includes 

examining, on a test basis, evidence supporting the amounts and 

disclosures in Form LS-513. An audit also includes assessing the 

accounting principles used and significant estimates made by 

management, as well as evaluating the overall presentation. We 

believe that our audit provides a reasonable basis for our 

opinion. 

In our opinion, Form LS-513 referred to above presents fairly, in 

all material respects, the compensation and medical payments made 

by _______ Company during the year ended December 31, 2001, as 

defined in the Act referred to in the first paragraph. 

This report is intended solely for the information and use of the 

board of directors and management of _______ company and the 

Division of Longshore and Harbor Workers' Compensation and should 

not be used for any other purpose. 

Signed 

Date