U.S. Department of Labor Employmenl Standards Administration 

Office of Workers· Compensation Programs 

Division of Longshore and 

May 1, 2003 Harbor Workers' Compensation 

Washington, D.C. 2021 o 

Fi le Number: 

NOTICE TO SELF INSURED EMPLOYERS #109 

SUBJECT: Excess Insurance Coverage Under the Longshore and 

Harbor Workers' Compensation Act and Extensions 

Please furnish the information requested below concerning your 

company's current excess insurance arrangements under the 

Longshore and Harbor Workers' Compensation Act and/or its 

extensions and return this Notice to the Office Workers' 

Compensation Programs, Division of Longshore and Harbor Workers' 

Compensation, at the above address by September 1, 2003. 

(1) Name of Self-Insured Employer: ----------------- ( 2) Address: ------------------------------

(4) Name of Excess Insurance Carrier: ---------------

{ 5) Policy Holder: ---------------------------

( 6) Pol Period: From To ---------- ------------ (7) Net Retention for One Accident: ----------------- (8) Amount of Maximum Limit: --------------------- ( 9) Printed Name and Title 

Information: 

Person Furnishing Above 

(10) Signature of Person Furnishing Information: 

(11) Telephone Number: Area Code ( 

If your excess insurance is layers with more than one 

insurance company, please indicate on the reverse of the Notice, 

or by covering letter, the name of each company and the policy 

numbers and limits. 

Michael Niss 

Director, Division of Longshore 

and Harbor Workers' Compensation 

Working for America's Workfon:e 
AUTHORIZED INSURANCE CARRIERS AND SELF-INSURED EMPLOYERS UNDER 

THE LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT, AND 

EXTENSIONS: 

The U.S. Department of Labor, Office of Workers' Compensation Programs, Division of 

Longshore and Harbor Workers' Compensation (DLHWC) renews the authority of each 

authorized insurance carrier and each authorized self-insurer effective July I of each year. 

Effective July 1, 2003, for these renewals, each insurance carrier and self-insurer is requested to 

acknowledge and agree to meet the following conditions for continuing authority: 

I. comply with all statutory and regulatory obligations, including meeting timeliness for paying 

benefits and reporting information [section 14(a)-(i)]; 

2. utilize the informal dispute resolution mechanisms in good faith by bringing only issues that 

are ready for resolution (i.e., all documentation is available) and sending representatives who 

are both prepared to and have authority to resolve issues; 

3. participate and cooperate with all efforts by professional and trade associations to self-police 

industry compliance; 

4. monitor and be held responsible for the performance in numbers 1 and 2 above of their third 

party administrators or other claims handlers; and 

5. respond to all penalty assessments in a timely manner. 

This statement, signed by a corporate officer below, should be returned to this Office prior to 

July 1, 2003. Please complete all of the required information. Any questions may be referred to 

the insurance branc~ of this Office at 202-693-0038. 

klJ}L 

MICHAEL NISS 

Director, Division of Longshore 

and Harbor Workers' Compensation 

Acknowledged: 

Signature of Officer 

Typed Name of Officer 

Title of Officer: 

Company Name: