1

12. Type of Notice

Notice of Payments

(Longshore and Harbor Workers' Compensation Act, 

as extended) 

U.S. Department of Labor

Office of Workers' Compensation Programs

OMB No. 1240-0041 

Expires: 08/31/2024

1. Date of Accident/Illness: 2. Carrier's No. 3. OWCP No.

4. Name of Injured Worker and Claimant if other than injured worker:

7. Date employee first lost time (Month, day, year) 8. Average Weekly Wage $ Compensation Rate $

 Subject to MIN/MAX rates

9. Payment Begin Date (Month, day, year)

If different than date of first lost time, state reason:

10. Employer continuing to pay the injured person's salary?

Yes No

If so, are salary continuation payments made in lieu of compensation 

payments.

Yes No

11. Date of first check ever issued on this claim 

(Month, day, year)

Initial (complete 6-11)

Interim

Final

13. State reason for interim or final payment notice:

14. Date last payment made:

15. ENTER ALL PAYMENTS MADE ON ACCOUNT OF DISABILITY

Attach continuation sheet to show additional periods, rates and amounts: TOTAL PAID:

16. ENTER OTHER PAYMENTS

Form LS-208 

Rev. Aug. 2021

2. Medical

TYPE OF DISABILITY

a

FROM

(Mo., day, yr.)

b

THROUGH

(Mo., day, yr.)

c

AMOUNT PAID

PER WEEK

d

NUMBER OF

WEEKS PAID e

TOTAL

f

PPD (non-schedule)

Disfigurement

Permanent partial

Percent

Part of body

a. Section 8(i) Settlement: 1. Compensation

b. Compensation for late payment per Sec. 14(e) or (f)

e. Beneficiary payments:

17. Employer Name:

(schedule loss)

c. Interest

d. Attorney Fee

f. Funeral Expenses

g. Sec. 44(c)(1) payment to the Special Fund

h. Commutation

EMPLOYEEPLEASE

READ

CAREFULLY

18. Name of insurance carrier or self-insured employer and administrator:

17a. Employer Address: 18a. Address and phone number of person whose name is shown in Box 18:

19. Signature of person authorized to sign for employer or carrier 20. Print name of authorized person: 21. Date of notice:

AS VERIFIED BY THE SIGNATURE BELOW, THIS FORM WAS MAILED TO THE CLAIMANT AND CLAIMANT'S REPRESENTATIVE

6. Compensation Disability type:

Select type:

Select type:

Information collected on this form will be used to determine whether compensation payments were timely and properly made under the 

Longshore and Harbor Workers’ Compensation Act, 33 U.S.C. 901 et seq., and its extensions, the Defense Base Act, 42 U.S.C. 1651 et seq., 

the Outer Continental Shelf Lands Act, 43 U.S.C. 1333(b), the Nonappropriated Funds Instrumentalities Act, 5 U.S.C. 8171, et seq., and the 

District of Columbia Workers’ Compensation Act of 1928, D.C. Code 1928, 36-501 et seq. 33 U.S.C. 914. Use of this form is mandatory. 33 U.

S.C. 914(c), (g). In Item 12, check the box for the type of payment you are reporting. Complete the remainder of the form as appropriate.

Any claim for compensation, to be valid, must be filed IN WRITING with the District Director, OWCP, WITHIN ONE YEAR after 

the date of injury or date of last payment of compensation. If you have any impairment of the body, serious disfigurement, 

or other disability from the injury which may handicap you in securing or maintaining employment you should submit a claim 

to the U. S. Department of Labor. Please be sure to include the OWCP Case Number.

5. Claimant's Address:
2

INSTRUCTIONS TO THE EMPLOYER/INSURANCE CARRIER 

A COPY OF THE FORM MUST BE MAILED TO THE CLAIMANT AND THE CLAIMANT'S REPRESENTATIVE.

This form must be filed with the Department of Labor to report disability or death compensation payments, as well as other statutory payments, in three 

situations. 

(1) You must file this form the same day you make a first payment of compensation. 20 C.F.R. 702.234. Failure to do so may result in assessment of a 

penalty under 33 U.S.C. 930(b) and (e). 

(2) You must file this form anytime you make an interim change in benefit payments. 20 C. F.R. 702.234. Failure to do so may result in assessment of 

a penalty under 33 U.S.C. 930(b) and (e) . 

(3) You must file this form within 16 days of final payment of compensation. 33 U.S.C. 914(g), 20 C.F.R. 702.235. Failure to do so will result in 

assessment of a penalty in an amount established under 20 C.F.R. 702.236. 

 

INSTRUCTIONS TO INJURED WORKER 

 

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, complete and sign an LS-203, Employee's Claim for Compensation. The form can be provided by your servicing 

district office nearest you https://www.dol.gov/agencies/owcp/dlhwc/lscontac or you can obtain the form through our website: https://www.dol.gov/

agencies/owcp/dlhwc/lsforms

 

 

TO SUBMIT FORMS TO DEPARTMENT OF LABOR 

 

Please be sure to include the OWCP Case Number and mail 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 

400 West Bay Street, Suite 63A, Box 28 

Jacksonville, FL 32202 

 

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

Access the SEAPortal directly at 

https://seaportal.dol.gov/portal/?program_name=LS

 

PRIVACY ACT STATEMENT 

 

The following information is provided in accordance with the Privacy Act of 1974, 5 USC 552a. (1) This collection of information is authorized under the 

Longshore and Harbor Workers' Compensation Act (LHWCA) and its extensions. (2) The information will be used to determine beginning and ending 

dates of compensation payments, types and amounts of compensation payments, and reasons for terminating compensation. (3) Completion of this 

form is MANDATORY. (4) Disclosures of this information may be made to: the claimant and his or her representative(s); the employer that employed 

the injured worker at the time of injury; the insurance carrier or other entity that secured the employer's compensation liability and their representative

(s); the Department of Labor's Office of Administrative Law Judges, or other person, board or organization, authorized or required to render decisions 

on claims or other matters arising in connection with a claim; Federal, state and local agencies 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; and other 

individuals, their representatives, and government agencies enforcing a legal obligation for alimony or child support. (5) An employer or insurance 

carrier's failure to timely provide the required information may result in penalties allowed by law. (6) This information is included in two Systems of 

Records, DOL/OWCP-3, 4, published at 81 Federal Register 25765, 25859-61 (April 29, 2016), or as updated and republished. 

 

Public Burden Statement 

 

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. The valid OMB control number for this information collection is 1240-0041. Public reporting burden for this collection of 

information is estimated to range between 5 and 15 minutes/hours 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. The obligation to respond to this 

collection is mandatory (5 U.S.C. 914(c)). 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, Office of Workers' Compensation Programs, 200 Constitution Avenue, N.W., 

Room S-3229, Washington, DC 20210. Note: Please do not return the completed LS-208 application to this address. 

Form LS-208 

Rev. Aug. 2021