11. 8(f) Relief is sought for:

Application for Special Fund Relief U.S. Department of Labor 

Office of Workers' Compensation Programs

OMB No.: 1240-0058 

Expires: 03/31/2026

INSTRUCTIONS: You must use this form to request Special Fund relief under Section 8(f) of the 

Longshore and Harbor Workers' Compensation Act, 33 U.S.C. 908(f), and extensions. You must 

attach supporting documentation as described in 20 CFR 702.321(a) and file the application within the 

time limits set forth in 20 CFR 702.321(b). 

 Or upload directly to the case file using the 

Secure Electronic Access Portal (SEAPortal) 

 

Access the SEAPortal directly at:

https://seaportal.dol.gov/portal/

Submit form to the OWCP/DFELHWC Central Mail Receipt site 

at the following address: 

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

DFELHWC 

400 West Bay Street, Suite 63A, Box 28 

Jacksonville, FL 32202

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

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

5. Explain how limitation of liability under Section 8(f) would apply to this injury.

6. Describe the nature of the injury, and disability/death:

7. List documentation to show extent of disability and date of maximum medical improvement, if applicable:

8. List documentation of pre-existing disability(ies) manifest to employer:

9. List evidence that explains how injury is not the sole cause of disability/death, and if permanent partial disability, how disability is 

substantially greater as a result of the manifested pre-existing disability(ies) listed above:

10. List any pending issues/disputes:

Permanent Partial Disability (PPD) - Hearing Loss

Permanent Partial Disability (PPD)

Permanent Total Disability (PTD)

12. If PPD, list documentation establishing injured workers' earning capacity:

Do NOT attach or submit irrelevant records.

Form LS-5
Form LS-5 

Page 2

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. Public burden for this collection of information is 

estimated to average 20 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 required to request approval of Special Fund Relief by the Office of Workers’ Compensation Longshore 

Program under 33 U.S.C. 908(f) and 20 C.F.R. 702.321. 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, 200 Constitution Avenue, NW, Room S-3524, Washington, D.C. 20210 and reference the OMB Control 

Number. Note: Please do not return the completed LS-5 to this address. 

Public Burden Statement 

DO NOT SEND COMPLETED FORMS TO THIS OFFICE. 

PRIVACY ACT STATEMENT 

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

collection of information is authorized under the Longshore and Harbor Workers’ Compensation Act (LHWCA) and its 

extensions. (2) This information will be used to determine if Special Fund Relief will be granted under the LHWCA. 

(3) Completion of this form is required to request Special Fund relief by the Office of Workers’ Compensation 

Longshore Program. (4) Disclosures of this information may be made to: the claimant and his or her 

representative(s); the employer, 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 (OALJ), 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) Failure to provide the information on this form may delay processing of the Special Fund 

application or result in the denial of Special Fund relief. (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.