10) Any payments made under a so-called “deductible” policy provision must be
reported by the insurance carrier that issued the policy.

11) Reports should include gross amounts paid and should not be offset to reflect
receipt of any 3TM party recoveries or subrogation actions.

12) When an employer continues to pay full salary to an employee, the amount of
compensation which is due the claimant must be reported. Payments must be
reported for employees who are disabled and given sheltered employment during the
period of recovery.

13) All payments made under state compensation statutes to concurrent longshore
workers must be reported. If the state amount exceeds that due under Longshore
only the lesser amount is reportable. If the state amount is less than that due under
Longshore then both must be reported. Such payments must be reported even if a
formal claim has not been filed under the Longshore Act and also must be reported if
subject to a state assessment formula.

REMINDERS:

1) Compensation may NOT be reduced or credited due to actual or anticipated
subsequent events, reversal on appeal, salary continuance, or credit under a State
Act.

2) All payments made under the DEFENSE BASE ACT must be reported and
segregated by Contracting Agency.

3) No credit is allowed for cases which may be recoverable in the future under the War
Hazards Compensation Act (WHCA). Once a case is accepted under the WHCA by
OWCP’s Division of Federal Employees’ Compensation, those claims need not be
reported for the calendar year in which they are actually accepted or any year in the
future. No credit will be given for amounts reimbursed from the WHCA.

4) Under the DISTRICT OF COLUMBIA COMPENSATION ACT only compensation and
medical payments made during calendar year 2015 where the injury date is prior to
2/26/82 should be reported.

5) If the employer/carrier reports zero ($0) payments a report must be submitted
showing the total payroll for covered Longshore employees during the calendar year.
If there is no payroll, the report must confirm this.

ACCURACY OF SUBMISSION:

The employer/carrier is ultimately responsible for reporting payments correctly. Third party
adjusters or other agents are responsible to their principals for accurate reports. When a
third party supplies the data the principal payer must sign and attest to the correctness of
the LS-513.

An independent certification is no longer required. Instead the Department of Labor will
conduct periodic random audits on a sample of employers and carriers each year. In support
of this all employers and carriers must maintain claims detail data which verify the figures
reported on the LS-513. Prior audits have resulted in improved and more accurate reporting
under the Act.


INSTRUCTIONS FOR COMPLETING FORM LS-513, REPORT OF PAYMENTS

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 2015. For DBA cases,
the number of cases and all compensation and medical payments must be reported
separately by the Contracting Agency. For example, the total number of cases and
payments for the Department of Defense must be reported in the fields indicated on the
form and cannot be combined with cases and/or payments from any other agency.

NOTE: A detailed listing must be submitted with the LS-513 supporting the
figures, and it must contain the following:

(1) Claimant’s Name (2) OWCP File Number (3) Social Security Number (4) Date
of Injury (5) State or Country of Injury (6) Act under which payments made (7)
Indemnity/Medical paid in CY 2015 (8) For DBA cases only, the Contracting Agency
as entered on the Employer's First Report of Injury or Occupational Illness (LS-202)

WHAT MUST BE REPORTED ON FORM LS-513:

1) All categories of compensation (under Sections 6, 8, 9, and 44(c)(1)) paid during
calendar year 2015 and reportable on an LS-208. This includes additional
compensation under Section 14(e) and (f). Compensation is considered paid when a
check is issued and not when the check is cashed.

2) Attorney's fees assessed against the employer/carrier under Section 28(a) & (b) are
NOT considered compensation; however, attorney's fees which are a lien on
compensation under 28(c) are reportable.

3) All penalties and interest payable to the claimant are considered compensation and
therefore reportable.

4) Section 8(i) settlements (including annuities) are fully reportable as compensation
and/or medical in the year paid.

5) Reimbursement to employer/carriers on cases where Section 8(f) relief is ultimately
granted are NOT to be deducted from total payments.

6) Medical payments must be reported on all lost time claims, including hearing loss
claims, closed cases, and claims paid under Section 8(f) and claims where only
compensation has been settled under Section 8(i).

7) Medical payments should include impartial medical examinations ordered by OWCP
but paid by the employer/carrier.

8) All payments for reimbursement from an excess/reinsurance Carrier or a
national/state assigned risk pool must be reported by the primary employer/carrier.

9) Any payments made directly to claimants by an excess/reinsurance Carrier must be
reported by the primary employer/carrier.

4


U.S. Department of Labor Siiswsotteehorema eres &

Harbor Workers’ Compensation
200 Constitution Avenue, Room C-4319 }
Washington, DC 20210 y

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January 13, 2016
Notice No. 155

To: Insurance Carriers and Self-Insured Employers under the Longshore and
Harbor Workers’ Compensation Act, and its extensions, and the District Of
Columbia Compensation Act

Subject: 2016 Advance Assessment for the Special Fund and Submission of Form
Ls-513 via the Longshore Electronic Access Forms Submission (LEAFS)

Notice: This notice transmits the 2016 Advance Assessment bill, and Form LS-513, Report
of Payments.

New This Year: While the statutory assessment process has not changed,
submission of the annual LS-513, Report of Payments, through the Longshore
Electronic Access Forms Submission (LEAFS) on-line web portal is new. Therefore,
please read all instructions carefully.

YOUR ASSESSMENTS

Authority: Section 44 of the Longshore and Harbor Workers’ Compensation Act (LHWCA)
provides for an annual assessment of each authorized insurance carrier and self-insured
employer for payment into the Special Fund, to provide for payments described under
Section 44(i). Separate accounts are maintained for the District Of Columbia Compensation
Act (DCCA) and the LHWCA and its extensions (Defense Base Act, Outer Continental Shelf
Lands Act and Non-Appropriated Fund Instrumentalities Act), and separate instructions
apply for reporting payments.

LHWCA Assessment: This notice transmits your LHWCA Advance Assessment bill,
calculated using: 1) your company’s reported compensation payments for calendar year
(CY) 2014, 2) the total of all compensation payments reported for CY 2014 (the latest data
available at this time), 3) CY 2015 Section 8(f) costs attributable to your company, 4) the
total of all CY 2015 Section 8(f) costs, and 5) the estimated CY 2016 LHWCA Special Fund
expenditures. The amount due for your CY 2016 Advance Assessment is shown at the
bottom of the billing form.

This notice also transmits Form LS-513, Report of Payments. Your company’s compensation
payments reported on the LS-513 for CY 2015, along with your share of the Special Fund's
costs during CY 2015 under Section 8(f), will serve as the basis for determining the amount
of your company's 2016 Final Assessment later this year; therefore, please ensure that the
report is correct in accordance with the instructions provided. The instructions for
completion and submission of this form are contained in this notice and also posted on our

website at: http://www,dol,aov/owep/dihwe

DCCA Assessment: This notice transmits your DCCA Advance Assessment bill, calculated
using: 1) your company’s reported compensation and medical payments for CY 2014, 2) the
total of all compensation and medical payments reported for CY 2014 (the latest data

1


available at this time), and 3) the estimated CY 2016 DCCA Special Fund expenditures. The
amount due for your CY 2016 Advance Assessment is shown at the bottom of the billing
form.

This notice also transmits Form LS-513, Report of Payments. Your company’s compensation
and medical payments reported on the LS-513 for CY 2015 will serve as the basis for
determining the amount of your company's 2016 Final Assessment later this year;
therefore, please ensure that the report is correct in accordance with the instructions
provided. The instructions for completion and return of this form are contained in this
notice and also posted on our website at: H

e For the DDCA assessment, please report only compensation and medical payments
where the date of injury was prior to July 26, 1982.

PAYING YOUR ASSESSMENT(S)

Payment of Advance Assessment Bill: The U.S. Treasury has mandated that payments
to the Federal government be conducted by FedWire/ACH credit to the greatest extent
possible. Do not combine payments for the LHWCA assessment and the DCCA assessment.

Payment Option 1 - Process a Fed Wire with Treasury New York to the account
below. Prior to the transaction, email your wire instructions to the Longshore
Assessment Questions email box: Longshore_Assessment_Questions@dol.gov
When emailing this information you must also include your company’s name, the bill
number (Bill No.) and sequence number (SEQ) as shown on the bill; the bill and
sequence number can be found on the top left hand corner of your bill.

Bank: Federal Reserve Bank of New York
Routing number: 021030004
Account number: 16150003

Payment Option 2 - Submit a check made payable to U.S. Department of Labor,
with a copy of the bill, to the address below. Please note that your check will be
converted to an electronic fund transfer and electronically debited to your account.
The original check will be destroyed, but a copy will be retained.

U.S. Department of Labor

Office of Workers’ Compensation

Division of Longshore and Harbor Workers’ Compensation
200 Constitution Avenue N.W., Room C-4319
Washington, D.C. 20210

SUBMITTING YOUR LS-513

Submission of LS-513 (And Supporting Documentation): The Longshore Electronic
Access Forms Submission (LEAFS) web portal has been deployed so that stakeholders can
electronically submit the Form LS-513, Report of Payments, and the required supporting
documentation to OWCP. Access LEAFS at the following web address:

https: //seaportal,dol-esa.gov/leaf

2


Electronic submission of the LS-513 and supporting documentation replaces the submission
of the documents via mail. If the documents are submitted through LEAFS, they do
not have to be mailed to OWCP,

Your company does not need to register or obtain a password to use LEAFS. You need only
your company’s OWCP Sequence (SEQ) number and your EIN (tax ID number). Both of
these can be found on the top left hand corner of the Advance Assessment bill that is
attached to this notice. Once you log in, the process can be completed in 5 quick and easy
steps.

Step 1 - Complete the form on-line

Step 2 - Print the form, sign and scan it

Step 3 - Upload the signed form (in pdf format)

Step 4 - Upload the supporting documentation (in pdf, tif or excel format)

Step 5 - Review the uploaded documents and submit

LEAFS will walk you through each step and then provide you a tracking number to confirm
receipt.

If no payments have been in the prior year, and the electronic LS-513 reflects $0 paid, Step
4 is not required to complete the submission. Also, if you submit the LS-513 and supporting
documentation and then later need to amend and resubmit the information, this can also be
done via LEAFS. OWCP/DHLWC will use the latest documents uploaded.

Note - If you are unable to use the LEAFS portal, you may still submit your LS-513 and
supporting documentation to the OWCP/DLHWC in Washington, DC. Please use the address
provided above for the submission of a paper check. Do not submit the form or the
supporting documentation via email.

YOUR DEADLINES

Due Dates:
Payment of the Advance Assessment bill is due by February 24, 2016.

The LS-513 (and supporting documentation) is due by March 24, 2016.
e Amendments are discouraged, but if necessary must be submitted by May 2, 2016.
e Late amendments may not result in an assessment change.

Questions: For questions pertaining to this year's advance assessment or the submission
of the LS-513, please submit your inquiry to the Longshore Assessment Questions email box
at the following address:

Longshore_Assessment_Questions@dol.gov

You may also call the OWCP/DLHWC Branch of Financial Management Insurance and
S at{202) 693-0038.

ANTONIO RIOS
Director, Division of Longshore and
Harbor Workers' Compensation