Notice of Employee's Injury or Death U.S.

Department of Labor
Longshore and Harbor Workers' Compensation Act, Employment Standards Administration
As Extended (See instructions on reverse) Office of Workers' Compensation Programs

This form should be furnished by the employer to any employee covered by the Longshore and Harbor Workers' OMB No. 1215-0160
Compensation Act or a related law who reports an occupational injury or illness to his/her employer.
This form is used to provide written notice of an injury or death. Notice is required to obtain a benefit (20 CFR 702.212).
The information will be used to determine entitlement to benefits. Persons are not required to respond to this collection
of information unless it displays a currently valid OMB control number. Print Reset
1. Employee's Name (Last, first, middle) 2. Home Mailing Address (Number, street, city, state, ZIP code)

Last Name First Name M.I. line 1: city:

line 2: st: zip:
country:
3. Date of Birth (Month, day, year) 4. Sex 5. Social Security Number 6. Home Telephone
Male (Required by Law) Area Code + Number
Female

7. Name and Address of Employer (Number, street, city, state, ZIP code) 8. Employee's Job Title

name:
line 1: city:
line 2: st: zip:
country:

9. Date of Injury (Month, day, year) 10. Hour of Injury 11. Place Where Injury Occurred

12. Name of Supervisor at Time of Injury 13. Did Employee Stop Work Due to 14. If Yes, Date Stopped
Injury?
Yes No

15. Cause of Injury (Explain in what way the injury or occupational illness was caused by employment)

16. Effects of Injury (Indicate parts of body affected or if death occurred)

NOTE: If reporting injury, employee signs Item 17; if reporting death, claimant or representative signs Item 18

17. 1 am requesting the employer named in item 7 to provide me appropriate compensation and medical care for my injury, and I hereby make
claim for all benefits to which I may be entitled under the Longshore and Harbor Workers' Compensation Act, or a related law.

Signature of Employee Date

Print Name
18. Request is hereby made to the employer named in Item 7 to provide appropriate death benefits to the survivors of the employee named in
Item 1, and a claim is hereby made for those death benefits to which these survivors may be entitled under the Longshore and Harbor
Workers' Compensation Act, or a related law.

Signature of Compensation Claimant or Representative of Claimant Date

Print Name
19. This notice is being personally delivered, or mailed, to the employer named in Item 7 (or his/her representative) and a copy is being sent to
the District Director of the Office of Workers' Compensation Programs by the party named in either Item 17 or 18 on this date.

Date

IMPORTANT NOTICE
Section 31 (a)(1) of the Longshore and Harbor Workers' Compensation Act , 33 U.S.C. 931 (a)(1), provides as follows: Any claimant or
representative of a claimant who knowingly and willfully makes a false statement or representation for the purpose of obtaining a benefit or
payment under this Act shall be guilty of a felony, and on conviction thereof shall be punished by a fine not to exceed $10,000, by
imprisonment not to exceed five years, or by both.
Form LS-201
Rev. Jan 1999
 INSTRUCTIONS TO EMPLOYEE <

IT IS IMPORTANT THAT WRITTEN NOTICE OF EMPLOYMENT-CAUSED INJURY OR ILLNESS BE GIVEN

PROMPTLY TO THE EMPLOYER AND THE DISTRICT DIRECTOR IN THE LOCAL OFFICE OF THE OFFICE OF
WORKERS' COMPENSATION PROGRAMS, U.S. DEPARTMENT OF LABOR.

Written notice needs to be given so that the District Director may see that an employee in case of injury, or
his or her survivors in case of death, receive all the benefits to which they may be entitled. No benefit need be
paid under the appropriate law unless a notice of injury or death is filed. [33 U.S.C. 912(a)]

WHO FILES Injured employees or survivors of employees whose deaths were due to employment covered by the Longshore
and Harbor Workers' Compensation Act, or its extensions.
Those Acts which extend the provisions of the Longshore and Harbor Workers' Compensation Act are:

Defense Base Act

Nonappropriated Fund Instrumentalities Act
Outer Continental Shelf Lands Act

WHEN TO FILE As soon as possible or within 30 days after the date of injury or death, or

Within 30 days after the employee or survivor first became aware, or in the exercise of reasonable diligence or by
reason of medical advice should have been aware, of a relationship between the injury or death and the
employment, or

in the case of an occupational disease which does not immediately result in a disability or death, within one year
after the employee or claimant becomes aware, or in the exercise of reasonable diligence or by reason of medical
advice should have been aware, of the relationship between the employment, the disease, and the death or
disability, or

In the case of hearing loss, within 30 days after receipt by an employee of an audiogram, with the accompanying
report thereon, indicating that the employee has suffered a loss of hearing.

The employer needs to have notice so that it or its insurance carrier may see that medical care is given promptly
WHY FILE and compensation payments for loss of income may be provided without delay.

WHERE TO FILE Give original copy to employer and send one copy to the District Director at the following address:

District Director
U.S. Department of Labor
Office of Workers' Compensation Programs (ESA)

FAILURE TO GIVE WRITTEN NOTICE MAY RESULT IN SOME LOSS OF BENEFITS.

PRIVACY ACT OF 1974 NOTICE

In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 522a), you are hereby notified that: (1) The Longshore and
Harbor Workers' Compensation Act, as amended and extended (33 U.S.C. 901 et seq.) is administered by the Office of Workers' Compensation
Programs of the U.S. Department of Labor. In accordance with this responsibility, the Office receives and maintains personal information on
claimants and their immediate families. (2) The information will be used to determine eligibility for the amount of benefits payable under the
Act. (3) The information may be used by other agencies or persons in handling matters relating, directly or indirectly, to the subject matter of
the claim, so long as such agencies or persons have received the consent of the individual claimant, or have complied with the provisions of
20 CFR 702. (4) Furnishing all requested information will facilitate the claims adjudication process; and the effects of not providing all or any
part of the requested information may delay the process, or result in an unfavorable decision or a reduced level of benefits.

IMPORTANT NOTICE

Section 31 (a)(1) of the Longshore and Harbor Workers' Compensation Act, 33 U.S.C. 931(a)(1), provides as follows: Any claimant or
representative of a claimant who knowingly and willfully makes a false statement or representation for the purpose of obtaining a benefit or
payment under this Act shall be guilty of a felony, and on conviction thereof shall be punished by a fine not to exceed $10,000, by
imprisonment not to exceed five years, or by both.

Public Burden Statement

We estimate that it will take an average of 15 minutes to complete this collection of information, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If
you have any comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, send them to the U.S. Department of Labor, Division of Longshore and Harbor Workers' Compensation, Room C4315,
200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE