August 2005 

Notice No. 119 

NOTICE TO INSURANCE CARRIERS UNDER THE LONGSHORE AND HARBOR WORKERS’ 

COMPENSATION ACT AND EXTENSIONS 

SUBJECT: ANNUAL REPORT OF OUTSTANDING LIABILITIES FORM LS-274 

 APPLICATION FOR SECURITY DEPOSIT DETERMINATION FORM LS-276 

Note: This Notice reflects changes pursuant to new regulations that 

will be effective on August 25, 2005. These regulations govern 

insurance carrier security deposits under the Longshore and Harbor 

Workers’ Compensation Act and its extensions. The new regulations 

contain major changes in the reporting requirements and the method of 

calculating carrier security deposits. Please read this Notice very 

carefully. The text of the regulations can be found at 70 Federal

Register pages 43234-37 (July 26, 2005) (to be codified at 20 

C.F.R.§§703.201-703.213) or online at www.gpoaccess.gov.

The most significant change is that the paid loss and loss reserve 

information required to be reported on the Form LS-274 must now be 

reported on a state by state basis with each state in which you write 

Longshore Act business listed separately on the Form LS-274 and Form 

LS-276. 

Form LS-274

In connection with the privilege to write workers’ compensation 

insurance under the Longshore and Harbor Workers’ Compensation Act and 

its extensions, this Office requires authorized insurance carriers to 

submit an annual report of outstanding workers’ compensation 

liabilities under the Act, as of June 30 of each year. You must file 

a completed LS-274 even if you apply for an exemption from the 

security deposit requirements (see below). The report now due should 

show the following information for each open Longshore case, with the 

cases listed separately by the state in which the case arose, as of 

June 30, 2005: 

1) Claimant’s Social Security Number (column a) 

NOTE: the carrier’s file number and employer number are not 

 required); 

 2) OWCP case number (column b) 

NOTE: Include the number for each open claim or claim on which 

benefits were paid during the reporting period. Include all 
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controverted claims and cases paid by the Special Fund where the 

employer/carrier continues to be liable for any medical benefits. 

It is the duty and responsibility of the insurance carrier to 

record the OWCP case numbers of all their claims and report those 

numbers on the LS-274 report; 

 3) Name of injured employee (column c); 

 4) Date of injury (column d) 

Note: Not the date of loss; 

 5) Nature of the injury (column e); 

 6) Amount of compensation and medical benefits paid through 

 June 30, 2005 (column f) 

Note: Include all compensation and medical benefits that have 

been paid on the case from the date of injury to the date of the 

report; 

 7) Estimate of future compensation benefit payments (column g) 

Note: This amount should be projected on a worst case basis. It 

 should not be discounted or reduced based on expectations of a 

 third party recovery, anticipated section 8(f) relief or 

 anticipated lump sum settlement. Do not include attorney fees 

 and/or other administrative costs or expenses; 

 8) Estimate of future medical benefit payments (column h) 

Note: Use the same criteria for reporting as in item 7 above; 

 9) Estimate of total compensation and medical payments expected 

 to be paid in the future (column i); 

 

10) Fatal cases are to be separately identified (column j); 

11) Third party cases are to be identified (column k). 

The report of outstanding liabilities may be submitted on Form LS-274, 

Report of Injury Experience of Insurance Carriers (copy enclosed), or 

in any other similar format that provides the same information, 

provided that all of the required information is submitted. Form LS274 is also available online at 

http://www.dol.gov/esa/owcp/dlhwc/lsforms.htm. Once again, please note 

that the cases for each state should be segregated and the states’ 

reports listed separately.

Insurance carriers must also provide separate reports for the Act and 

each of its extensions, (i.e., Longshore and Harbor Workers’ 

Compensation Act, Outer Continental Shelf Lands Act, Defense Base Act, 

and Nonappropriated Fund Instrumentalities Act). Also, insurance 
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carriers with subsidiaries that write insurance under these Acts must 

provide a separate report for each subsidiary. Please include the 

applicable Department of Labor authorization number on each report

submitted. 

All open claims reported are to be listed state by state, 

chronologically, by accident date, for each July 1 through June 30 

period. Subtotals of the estimated future payments requested in the 

first paragraph above or as called for in column (g), (h), and (i) of 

Form LS-274 are to be provided for each period. 

Finally, each report should reflect a Grand Total for each state for 

all estimated future payments. This insurance carrier’s annual report 

of outstanding liabilities is due no later than November 1, 2005 and 

must include a separate notarized statement signed by a corporate 

officer attesting to the completeness and accuracy of the information 

provided. 

Certification of the Report of Outstanding Liabilities by other than 

corporate officers as indicated above will not be accepted. The 

signed statement should be on a separate letterhead. Please indicate 

in your correspondence the name and telephone number of the person to 

be contacted in the event there are any questions. 

If an insurance carrier has no outstanding workers’ compensation 

liabilities under the Acts, an annual report noting the absence of 

current liabilities must be filed for each company and each authorized 

subsidiary. This report must also be accompanied with the same 

separate notarized statement from a company official as mentioned 

earlier in this notice. 

Form LS-276

In addition to Form LS-274, you must complete and file Form LS-276, 

Application for Security Deposit Determination (copy enclosed). This 

form is also available online at 

http://www.dol.gov/esa/owcp/dlhwc/lsforms.htm. If you are seeking an 

exemption from the security deposit requirements based on your 

financial standing, you must include documentation establishing your 

current rating and your rating from the immediately preceding year 

from each insurance rating service designated by OWCP and posted on 

the internet at http://www.dol.gov/esa/owcp/dlhwc/lstable.htm. 

Ratings from A.M Best Company, Weiss Insurance Reports and Standard & 

Poors are presently accepted. Insurance carriers with subsidiaries 

that write insurance under the Longshore Act or its extensions must 

complete a separate application for each subsidiary. 

The totals of the obligations for each state listed in detail on your 

Form LS-274 should be shown in Number 7 on your Form LS-276. Using 
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the values listed on the state guaranty fund summary provided by this 

Office (copy enclosed), you should then apply the relevant value of 

either 100%, 33% or 0% for each state in order to calculate the 

“Estimated Deposit” for that state. For example, 

a. State b. Total c. Percent d. Estimated 

 Obligations Unsecured Deposit 

West Virginia $200,000 100% $200,000 

Maryland $200,000 0% $ 0 

Delware $200,000 33% $66,000 

The LS-276 must be signed by an appropriate officer of the carrier. 

If the carrier is a corporation, you must also affix the corporate 

seal. 

Mail your completed annual report(s) and application(s) for security 

deposit determination to this address: 

U. S. Department of Labor 

ESA/OWCP/DLHWC, Room C-4315 

200 Constitution Ave., NW 

Washington, DC 20210 

Attn: Michael Niss 

Failure to submit an annual report or application for security deposit 

determination as outlined in this Notice may result in the termination 

of your authorization to write insurance under the Longshore Act and 

its extensions. 

This insurance authorization cannot be transferred, and it cannot be 

assigned. Any change involving the corporate name, structure, 

ownership, organization, etc., may affect the insurance authority and 

must be brought to the attention of this Office prior to the effective 

date of the event. 

For further information, contact Ms. Linda Myer at (202) 693-0289 or 

Ms. Amanda Smith at (202) 693-0968.

MICHAEL NISS 

Director, Division of 

Longshore and Harbor 

Workers’ Compensation 

Enclosure