7. These Stipulations Include (check all that apply):

U.S. Department of Labor 

Office of Workers' Compensation Programs

Stipulation Approval Request

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

Or upload directly to the case file using the 

Secure Electronic Access Portal (SEAPortal) 

 

Access the SEAPortal directly at: 

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

OMB No.: 1240-0058 

Expires: 03/31/2026

You must use this form to request a District Director compensation order approving joint stipulations. 

You must attach the signed stipulations you want approved.

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. Average Weekly Wage: 6. Compensation Rate

Compensation Medical Treatment Attorney Fees

8. ENTER ALL PAYMENTS TO BE MADE PURSUANT TO THESE PROPOSED STIPULATIONS

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. 

9. Amount Due for Attorney fee:

10. Check if Additional Compensation will be paid as a result of these Stipulations:

11. Additional Information (optional):

Form LS-9
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. 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 obtain a compensation order approving 

stipulations from the Office of Workers’ Compensation Longshore Program. See 20 C.F.R. 702.315(a). 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-9 to this office.

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) The information will be used to determine whether a compensation order 

should be issued based on stipulations entered into by the parties to a LHWCA claim. (3) Completion of this 

form is required to obtain a compensation order approving stipulations from 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 claim, the payment of benefits, or may result in an 

unfavorable decision or reduced level of benefits. (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.

PRIVACY ACT STATEMENT 

Form LS-9 

Page 2