U.S. Department of Labor 

July 16, 2001 

Employment Standards Administration 

Office of Workers' Compensation Programs 

Division of Longshore and 

Harbor Workers' Compensation 

Washington, D.C. 20210 

File Number: 

Notice 96 

NOTICE TO INSURANCE CARRIERS UNDER THE LONGSHORE AND HARBOR 

WORKERS' COMPENSATION ACT AND EXTENSIONS 

SUBJECT: ANNUAL REPORT OF OUTSTANDING LIABILITIES FORM LS-274 

In connection with the privilege to write workers' compensation 

insurance under the Longshore and Harbor Workers' Compensation 

Act, and extensions, this Office requires certain authorized 

insurance carriers to submit an annual report of outstanding 

workers' compensation liabilities under the Act, as of June 30 of 

each year. The report now due should show the following 

information for each open case as of June 30, 2001: instead of 

the employer's or carrier's case number, please substitute the 

claimant's Social Security Number; OWCP case number; name of 

injured employee; date of injury; nature of injury; amount of 

compensation and medical benefits paid through June 30, 2001; 

estimate of future compensation benefit payments; estimate of 

future medical benefit payments, and estimate of total 

compensation and medical payments expected to be paid in the 

future. Fatal cases are to be separately identified. 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. 

Insurance carriers must 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 carriers with subsidiaries authorized under the Act 

must provide separate reports for each subsidiary, Please 

include the applicable Department of Labor authorization number 

on each report submitted. 

All open claims reported are to be listed 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 all 

estimated future payments. This insurance carrier's annual 

report of outstanding liabilities is due no later than September 

1, 2001 and must include a separate notarized statement signed by 

a corporate officer attesting to the completeness and accuracy of 

the information provided. 

Working for America's Workforce 
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Certification of the Report of Outstanding Liabilities by other 

than corporate officers as stated 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, a negative report must be filed for 

each company and each authorized subsidiary. A negative report 

must also be accompanied with the same separate notarized 

statement from a company official as mentioned earlier in this 

notice. 

Your report should be addressed as follows: 

U.S. Department of Labor 

ESA/OWCP/DLHWC, Room C-4315 

200 Constitution Avenue, N.W. 

Washington, D.C. 20210 

Attention: Michael Niss 

Failure to submit the complete report as outlined in this Notice 

may result in the termination of your authorization to write 

insurance under the Act(s). 

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 Mr. Peter La Lena at (202) 693-0910. 

Sin~L 

MICHAEL NISS 

Director, Division of 

Longshore and Harbor 

Workers' Compensation 

Enclosure 
~ 

Report of lnjury._Experlence of 

lllSUIIANCE CAJIRI&II 

1HSU!Ull<C£ CAl\111£11 

Social 

Securit owcrc.. .. 

- - Nuno ol lnJur•d £,nployH 

,., lb) (<) 

, , 

U.S. Department of Labor 

EmplOymrt'I; SttndatdJ Admlnb11a!ion 

Offict of W0tktt& C~u1ion PrOQtam, 

l ?1,g1hof • at\d Hat bot Worha • Compenu1ion ,,og,ams 

Carrier .idd,HJ (N~ &t'td tlfHI. clly •• ,.,. and 1lp COOi} Rtpo,ting 

f>•lod 

. Eallmata of E1ttm&tt of 

Nati.we Ol lnJ\Ky Fu!urt Com- Fvluta μ:.a;.. 

UH abbf •vl•liont • Amount of pena.a1lon cal Jtaym•m• 

0.lt ol ln)v,y ft •• IP,♦ tie. S.n•fitt Paid Pay~lt (OiHbtllty caua 

' only) 

(di (tl (ll ta) (M 

~ l'orm LS-274 

l Us.tAll~CHH j 0.lt of A<lf)Q<I 

u ot tr. 0-1, of I 

TOIi Rt....vt ! 

Ettlmatt of Ch«k OWCI' 

to,af Futvt• lhbd c-• VatHI•. 

~lAliotl Patty Fattl canon 

p. ym.tllt , .... CUH (lUYt 

(O + h) 8ltt1k) 

(I) .. UL t•l (I) 

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