U.S. Department of Labor Office of Workers’ Compensation Programs
Divsion of Longshore and

Harbor Workers’ Compensation
Washington, D.C. 20210

OCT 11 201 File Number:

Notice No. 136

NOTICE TO INSURANCE CARRIERS AND SELF-INSURED EMPLOYERS UNDER
THE LONGSHORE AND HARBOR WORKERS’ COMPENSATION ACT, AND
OTHER INTERESTED PERSONS

SUBJECT: Newly Revised Form LS-206

Mandatory Longshore Form LS-206, Payment of Compensation Without Award, has been
revised August, 2011. The revised form is now available for download and printing from the
DLHWC website. http://www.dol.gov/owep/dlhwe/lsforms.htm

Effective November 01, 2011, the revised version of the form should be used. All prior versions
of the form are obsolete.

The August 2011 version of Form LS-206 contains changes and requires the following
mandatory information and action:

° The instruction section at the top of the form has been revised and
advises the form “is to be filed with the District Director not later than the same
day that first payment is made.”

° Adds Box 9(a) to allow the filer to check a yes or no block: “For DBA cases only,
is the employer continuing to pay the injured person’s salary?”

° Adds Box 9(b) to allow the filer to check a yes or no block: “If so, are these salary
continuation payments being made in lieu of compensation payments?”

Questions regarding this revised form LS-206 should be addressed in writing to, Miranda Chiu,
Acting Director Division of Longshore and Harbor Workers’ Compensation, 200 Constitution
Ave. N.W., Room C-4315 Washington, DC 20210. Also, you may send your inquiries to

OWCP-public@dol.gov.

M A. CHIU

Acting Director, Division of
Longshore and Harbor
Workers' Compensation


Payment Of Compensation Without Award U.S. Department of Labor

(Longshore and Harbor Workers’ Compensation Act, Office of Workers' Compensation Programs
as extended)
OMB No. 1240-0043
NOTE: This Notice is to be filed with the District Director not later FOR OFFICE USE
than the same day that first payment is made. A copy should 1. OWGP No. 2. CARRIER'S No.
be sent to the payee(s) AND to their attorney (if represented).

3. Name of injured person (First, middle, last - please print or type)

4, Address of injured person (Number, street, city, state and ZIP code)

United States

5. Date of accident or first illness (Month, day, year) 6. Date disability began (Month, day, year)

7. Name of injured, or dependents of injured, to whom compensation will be paid

multiplied by 2/3 compensation rate $

Average weekly wage $
(Mark if maximum rate is being paid) [Yes [7 no
9. Compensation will be paid from - Enter month, day, year. 9a. For DBA cases only, is the employer continuing to pay the
injured person's salary? Tes Tino
until notice is given that payment has been stopped or suspended 9b. If so, are these salary continuation payments being made in
10. Date of first payment (Month, day, year.) lieu of compensation payments? rive Pv.

11. Has medical care and treatment been provided by a physician or hospital chosen by the injured person?
(Mark appropriate box) [ves Tine

12. Name and address of employer (Name, number, street, city, state, ZIP code and country)

United States

13. Name and address of insurance carrier and/or claim administrator(Name, number, street, city, state, ZIP code and country)

United States

14. Authorized signature

15. Type or print title and name of person whose signature appears in item 14 Phone number 16. Date signed(mm-dd-yyyy)

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 contro! number. Public reporting burden for this collection of information is estimated to average 10 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 accordance with
20CFR 702.234. 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, Room C4315, 200 Constitution Avenue, NW, Room C-4315,

Washington, D.C. 20210, and reference the OMB Control Number.
DO NOT SEND COMPLETED FORMS TO THIS OFFICE.

Form LS-206
Rev. August 2011