INSTRUCTIONS FOR COMPLETING FORM LS-513, REPORT OF PAYMENTS

GENERAL - Pursuant to Section 44 of the Longshore and Harbor Workers' Compensation
Act, all authorized insurance carriers and self-insured employers under the Longshore Act
and extensions, including the District of Columbia Compensation Act, are required each year
to complete and file with the Office of Workers’ Compensation Programs the attached Form
LS-513. The form must be completed to show the number of cases and all compensation
and medical payments made under the Act(s) during calendar year 2018. For DBA cases,
the number of cases and all compensation and medical payments must be reported
separately by the Contracting Agency. For example, the total number of cases and
payments for the Department of Defense must be reported in the fields indicated on the
form and cannot be combined with cases and/or payments from any other agency.

NOTE: A detailed listing must be submitted with the LS-513 supporting the
figures, and it must contain the following:

(1) Claimant’s Name (2) OWCP File Number (3) Social Security Number (4) Date
of Injury (5) State or Country of Injury (6) Act under which payments made (7)
Indemnity/Medical paid in CY 2017 (8) For DBA cases only, the Contracting Agency
as entered on the Employer's First Report of Injury or Occupational Illness (LS-202)

WHAT MUST BE REPORTED ON FORM LS-513:

1) All categories of compensation (under Sections 6, 8, 9, and 44(c)(1)) paid during
calendar year 2018 and reportable on an LS-208. This includes additional
compensation under Section 14(e) and (f). Compensation is considered paid when a
check is issued and not when the check is cashed.

2) Attorney's fees assessed against the employer/carrier under Section 28(a) & (b) are
NOT considered compensation; however, attorney's fees which are a lien on
compensation under 28(c) are reportable.

3) All penalties and interest payable to the claimant are considered compensation and
therefore reportable.

4) Section 8(i) settlements (including annuities) are fully reportable as compensation
and/or medical in the year paid.

5) Reimbursement to employer/carriers on cases where Section 8(f) relief is ultimately
granted are NOT to be deducted from total payments.

6) Medical payments must be reported on all lost time claims, including hearing loss
claims, closed cases, and claims paid under Section 8(f) and claims where only
compensation has been settled under Section 8(i).

7) Medical payments should include impartial medical examinations ordered by OWCP
but paid by the employer/carrier.

8) All payments for reimbursement from an excess/reinsurance Carrier or a
national/state assigned risk pool must be reported by the primary employer/carrier.

9) Any payments made directly to claimants by an excess/reinsurance Carrier must be
reported by the primary employer/carrier.

5


DEADLINES

Due Dates:
Payment of the Advance Assessment bill is due by March 1, 2019.

The LS-513 (and supporting documentation) is due by March 15, 2019.
e Amendments are discouraged, but if necessary, must be submitted by March 15,
2019.
e Any amendments submitted beyond March 15, 2019 may not be considered in the
final assessment bill.

Questions: For questions pertaining to this year's advance assessment or the submission
of the LS-513, please submit your inquiry to the Longshore Assessment Questions email box
at the following address:

Longshore_Assessment_Questions@dol.gov

You may also call the OWCP/DLHWC Branch of Financial Management, Insurance and
Assessments at (202) 354-9620.

Sanh eee

Directo, Division of Longshore and
Harbor Workers' Compensation


10) Any payments made under a so-called “deductible” policy provision must be
reported by the insurance carrier that issued the policy.

11) Reports should include gross amounts paid and should not be offset to reflect
receipt of any 3 party recoveries or subrogation actions.

12) When an employer continues to pay full salary to an employee, the amount of
compensation which is due the claimant must be reported. Payments must be
reported for employees who are disabled and given sheltered employment during the
period of recovery.

13) All payments made under state compensation statutes to concurrent longshore
workers must be reported. If the state amount exceeds that due under Longshore
only the lesser amount is reportable. If the state amount is less than that due under
Longshore then both must be reported. Such payments must be reported even if a
formal claim has not been filed under the Longshore Act and also must be reported if
subject to a state assessment formula.

1) Compensation may NOT be reduced or credited due to actual or anticipated
subsequent events, reversal on appeal, salary continuance, or credit under a State
Act.

2) All payments made under the DEFENSE BASE ACT must be reported and
segregated by Contracting Agency.

3) No credit is allowed for cases which may be recoverable in the future under the War
Hazards Compensation Act (WHCA). Once a case is accepted under the WHCA by
OWCP’s Division of Federal Employees’ Compensation, those claims need not be
reported for the calendar year in which they are actually accepted or any year in the
future. No credit will be given for amounts reimbursed from the WHCA.

4) Under the DISTRICT OF COLUMBIA COMPENSATION ACT only compensation and
medical payments made during calendar year 2018 where the injury date is prior to
2/26/82 should be reported.

5) If the employer/carrier reports zero ($0) payments a report must be submitted
showing the total payroll for covered Longshore employees during the calendar year.
If there is no payroll, the report must confirm this.

ACCURACY OF SUBMISSION:

The employer/carrier is ultimately responsible for reporting payments correctly. Third party
adjusters or other agents are responsible to their principals for accurate reports. When a
third party supplies the data the principal payer must sign and attest to the correctness of
the LS-513.

An independent certification is no longer required. Instead the Department of Labor will
conduct periodic random audits on a sample of employers and carriers each year. In support
of this all employers and carriers must maintain claims detail data which verify the figures
reported on the LS-513. Prior audits have resulted in improved and more accurate reporting
under the Act.


U.S. Department of Labor — Sites0f Workers Compensation Programs

Harbor Workers’ Compensation
200 Constitution Avenue, Room C-4319
Washington, DC 20210

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January 29, 2019
Notice No. 170

To: Insurance Carriers and Self-Insured Employers under the Longshore and
Harbor Workers’ Compensation Act, and its extensions, and the District Of
Columbia Compensation Act

Subject: 2019 Advance Assessment for the Special Fund and Submission of Form
LS-513 via the Longshore Electronic Access Forms Submission (LEAFS).

Notice: This notice provides information on the 2019 Advance Assessments, the preferred
method of payment and submission of Form LS-513, Report of Payment.

Electronic submission of LS-513: You can submit the LS-513 and supporting
documentation electronically via the Longshore Electronic Access Forms Submission
(LEAFS) on-line web portal, the preferred method of submission which is accessed
at: https://seaportal.dol-esa.gov/leaf

Payment instructions: When submitting payment, follow the payment instructions
located on pages 2 and 3.

YOUR ASSESSMENTS

Authority: Section 44 of the Longshore and Harbor Workers’ Compensation Act (LHWCA)
provides for an annual assessment of each authorized insurance carrier and self-insured
employer for payment into the Special Fund, to provide for payments described under
Section 44(i). Separate accounts are maintained for the District Of Columbia Compensation
Act (DCCA) and the LHWCA and its extensions (Defense Base Act, Outer Continental Shelf
Lands Act and Non-Appropriated Fund Instrumentalities Act), and separate instructions
apply for reporting payments.

LHWCA Assessment: Your LHWCA Advance Assessment bill is calculated using: 1) your
company’s reported compensation payments for calendar year (CY) 2017; 2) the total of all
compensation payments reported for CY 2017 (the latest data available at this time); 3) CY
2018 Section 8(f) costs attributable to your company; 4) the total of all CY 2018 Section
8(f) costs; and 5) the estimated CY 2019 LHWCA Special Fund expenditures. The amount
due for your CY 2019 Advance Assessment is shown at the bottom of the billing form.

This notice provides instructions on completing Form LS-513, Report of Payments,
electronically through LEAFS for CY 2018, the preferred method of reporting. Your
company’s compensation payments reported on the LS-513 for CY 2018, along with your
share of the Special Fund's costs during CY 2018 under Section 8(f), will serve as the basis
for determining the amount of your company's 2019 Final Assessment later this year;
therefore, please ensure that the report is correct in accordance with the instructions
provided. The instructions for completion and submission of this form are contained in this
notice.


DCCA Assessment: Your DCCA Advance Assessment bill is calculated using: 1) your
company’s reported compensation and medical payments for CY 2017; 2) the total of all
compensation and medical payments reported for CY 2017 (the latest data available at this
time); and 3) the estimated CY 2019 DCCA Special Fund expenditures. The amount due for
your CY 2019 Advance Assessment is shown on the bill.

This notice also provides instructions on completing Form LS-513, Report of Payments,
electronically through LEAFS for CY 2018, as the preferred method of reporting. Your
company’s compensation and medical payments reported on the LS-513 for CY 2018 will
serve as the basis for determining the amount of your company's 2019 Final Assessment
later this year; therefore, please ensure that the report is correct in accordance with the
instructions provided.

« For the DCCA assessment, please report only compensation and medical payments
where the date of injury was prior to July 26, 1982.

PAYING YOUR ASSESSMENT(S)

Payment of Advance Assessment Bill: The U.S. Treasury has mandated that payments
to the Federal government be conducted by Fedwire/ACH credit to the greatest extent
possible. Do not combine payments for the LHWCA assessment and the DCCA assessment.

Preferred Payment Option - To process a Fedwire with Treasury New York,
you_MUST email your wire instructions to the Longshore Assessment Questions
email box: Longshore_Assessment_Questions@dol.gov with the subject line
“WIRE INSTRUCTIONS?” prior to the transaction. When emailing this information
you must also include your company’s name, the bill number (Bill No.) and sequence
number (SEQ) as shown on the bill; the bill and sequence number can be found on
the top left hand corner of your bill.

Bank: Federal Reserve Bank of New York
Routing number: 021030004
Account number: 16150003

Alternative Payment Option - Submit a check made payable to U.S. Department
of Labor, with a copy of the bill, to the address below. Please note that your check
will be electronically debited to your account.

U.S. Department of Labor

Office of Workers’ Compensation

Division of Longshore and Harbor Workers’ Compensation
200 Constitution Avenue N.W., Room C-4319
Washington, D.C. 20210

Do Not Combine Payments:

e Do not combine payments for subsidiary companies that fall under
your control.

v If paying by wire, wire instructions must clearly reflect the subsidiaries
for which you are forwarding payment and the individual amounts
remitted.


v If paying by check, submit a separate check for each subsidiary with a
copy of corresponding bill attached.

e Do not combine payments for the LHWCA assessment and the DCCA
assessment.

e Do not net credits against balances due. Payment should reflect the full
amount shown on the individual bill.

SUBMITTING YOUR LS-513

Submission of LS-513 (and Supporting Documentation): The Longshore Electronic
Access Forms Submission (LEAFS) web portal is available to stakeholders to electronically
submit the Form LS-513, Report of Payments, and the required supporting documentation
to OWCP. This is the preferred method for submission. Access LEAFS at the following web
address:

Electronic submission of the LS-513 and supporting documentation replaces the submission
of the documents via mail. If the documents are submitted through LEAFS, do not
mail to OWCP..

To use LEAFS, only your company’s OWCP Sequence (SEQ) number and EIN (tax ID
number) are needed to access the portal. Both of these can be found on the top left hand
corner of the Advance Assessment bill. Once you log in, the process is completed in five (5)
quick and easy steps.

Step 1 - Complete the form on-line

Step 2 - Print the form, sign and scan it

Step 3 - Upload the signed form (in pdf format)

Step 4 - Upload the supporting documentation (in pdf, tif or excel format)

Step 5 - Review the uploaded documents and submit

LEAFS will walk you through each step and provide a tracking number to confirm receipt.

If no payments have been made in the prior year, and the electronic LS-513 reflects $0
paid, Step 4 is not required to complete the submission. Also, if you submit the LS-513 and
supporting documentation and then later need to amend and resubmit the information, this
can also be done via LEAFS. OWCP/DHLWC will use the latest documents uploaded.

Note - If you are unable to use the LEAFS portal, you may submit your LS-513 and
supporting documentation to the OWCP/DLHWC in Washington, DC. The LS-513 form can
be accessed through the DLHWC website at: https://www.dol.gov/ow Ihwe/, under the
Longshore Forms link. Please use the address provided above for the submission of the
form. Do not submit the form or the supporting documentation via email.