Get Form Ls 210

Filling out the Form LS 210 is essential for reporting accidents or occupational illnesses. This guide provides clear, step-by-step instructions to support users in completing the form accurately and efficiently.

Follow the steps to complete the Form LS 210 online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Enter the injured employee's OWCP number in the designated field at the top of the form.
3. Provide the carrier's number in the appropriate field immediately following the OWCP number.
4. Fill in the date of the accident using the format Month, day, year.
5. Complete the address of the injured employee, ensuring all details including number, street, city, state, and ZIP code are accurately entered.
6. For the initial period of disability, specify the inclusive dates by filling out both 'From' and 'Through' fields, along with the date returned to work, if applicable.
7. If this report covers additional periods of disability, list each subsequent period using the same inclusive date format.
8. Indicate whether the employee received medical attention. If yes, provide dates, names, and addresses of treatment providers.
9. State whether the employee was treated by their choice of physician by selecting 'Yes' or 'No' and providing explanations if necessary.
10. Enter the name of the employer's firm and the employer's address.
11. The authorized person must sign the form. Fill in their official title and phone number in the designated fields.
12. Record the date of the report in the format Month, day, year before finalizing the form.

Complete your Form LS 210 online today to ensure prompt reporting and processing.