U. S. Department of Labor Office of Workers’ Compensation Programs
Division of Longshore and
Harbor Workers’ Compensation
Washington, DC 20210

May 26, 2015
Industry Notice No. 151

TO: INSURANCE CARRIERS AND SELF-INSURED EMPLOYERS UNDER THE
LONGSHORE AND HARBOR WORKERS’ COMPENSATION ACT (LHWCA), AND ITS
EXTENSIONS, AND OTHER INTERESTED PERSONS

SUBJECT: Newly Revised Form LS-207 (Notice of Controversion of Right to
Compensation) and LS-208 (Notice of Final Payment or Suspension of
Compensation Payments)

Mandatory Longshore Forms LS-207, Notice of Controversion, and LS-208, Notice of Final
Payment or Suspension of Compensation Payments, have been revised. These revised
forms are now available on the Office of Workers’ Compensation Programs (OWCP) Division
of Longshore and Harbor Workers’ Compensation (DLHWC) website:

http://www.dol.gov/owcp/dihwe/Isforms.htm

The revised versions of these two forms should now be used. All prior versions of
the forms are considered obsolete.

Form LS-207: http://www.dol.gov/owcp/dihwc/Is-207.pdf

OWCP made changes to Form LS-207, including reordering the list of parties and addresses,
expanding the size of boxes used for responding, and adding more instructions, including a
back page. Specifically, the following changes have been made:

e The instructions at the top of the form have been updated to:

o Direct submission of the form to DLHWC’s Central Mail Receipt site (see
Industry Notice No. 144) or to the Secure Electronic Access Portal (SEAPortal)
(see Industry Notice No. 148);

o Include a statement that the employer or carrier must mail a copy of the form
to the injured employee and employee's legal representative, if one has been
retained; and

o Remove the requirement that the form be submitted in triplicate as only one
copy is necessary.

e Boxes 4, 5, 6, 7, and 8 - The revised form reordered the parties of the claim and
aligned the city, state and zip code on the same line in the address field. Also,
former Box 5, which identified the Act, has been changed to Box 8 and moved to the
middle of the form.

e Box 13 - This box is still designated for the signature of the person submitting the
form; however, signature in this block now serves as confirmation that a copy of the


form was mailed to the injured employee and his/her legal representative, if one has
been retained. Box 17(a) and (b) on the prior version of the form have, therefore,
been removed.

« An“Explanation to Employee” has been added to the bottom of the form so that the
injured worker can better understand the meaning of the form and what action
should be taken if he/she objects to the notice.

e The Public Burden Statement was moved to the backside of the form below a newly
added Privacy Act Statement.

« Instructions have been added to the backside of the form to explain the time
requirements to file a claim, how to file a claim, where to obtain claim forms, and
where to submit documents. The DLHWC’s Central Mail Receipt address and the
SEAPortal website have also been provided.

Form LS-208: http://www.dol.gov/owcp/dihwc/Is-208.pdf

OWCP made changes to Form LS-208, including reorganizing the report of payments made on
account of death and other payments, expanding the report of payments made for scheduled
permanent partial disability, and adding more instructions, including a back page. Specifically,
the following changes have been made:

e The instructions at the top of the form have been updated to:

o Direct submission of the form to DLHWC’s Central Mail Receipt site or to the
Secure Electronic Access Portal (SEAPortal); and

o Incorporate the previously separate instruction (under prior Box 3) to the
employer or carrier to mail a copy of the form to the injured employee and
his/her legal representative, if one has been retained.

* Box 3(a) - This box has been completed with DLHWC’s Central Mail Receipt address
and the SEAPortal website.

* Box 7(a) - This section has been changed to “Date first check issued” rather than the
prior wording, “Date of first payment of compensation,” to provide more clarity
regarding the date that should be entered in this box. (This information should be
the same as the date on Box 10 of the Form LS-206, Payment of Compensation
Without Award.)

e Box 14 - The boxes for the types of disability have been reordered slightly from the
prior version of the form and specific references for the percent and part of the body
have been added to the Permanent Partial (schedule loss) section. The reporting of
payments for facial or other disfigurement has been moved to Box 16.

e Box 15 - This section is still reserved for payments made on account of death, but it
has been modified to report payments made to beneficiaries in the same manner as
reporting payments for disability. Payments of funeral expenses and Section
44(c)(1) to the Special Fund were moved to Box 16.

« Box 16 - In addition to the changes noted above, this section has been modified to
separate the payment of compensation and medical benefits under Section 8(i).


¢ Box 17 - This is now the signature block. A statement has been added indicating
signature in this block verifies that a copy of the form was mailed to the injured
employee and his/her legal representative, if one has been retained. The check
boxes indicating that copies had been sent have been removed.

e The message, “Employee - Please Read Carefully,” has been edited and a reference
to the reverse side of the form for further instructions has been added. The
message provides clarity so that the claimant knows what steps to take to file for
additional compensation.

« The Public Burden Statement was moved to the reverse side of the form below a
newly added Privacy Act Statement.

« Instructions have been added to the backside of the form to explain the time
requirements to file a claim, how to file a claim, where to obtain claim forms, and
where to submit documents. The DLHWC’s Central Mail Receipt address and the
SEAPortal website have also been provided.

Any questions regarding this Industry Notice or the revised forms should be directed to the
DLHWGf ranch of Policy, Regulations and Procedures, Washington, DC.

ANTONID A. RIOS
Director, Division of
Longshore and Harbor Workers’ Compensation