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Get Form Ls 201

Ation Programs www.dol.gov/owcp/dlhwc/index.htm This form should be furnished by the employer to any employee covered by the Longshore and Harbor Workers' 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. The information will be used to determine entitlement to benefits. 1. Employee's Name (Last, First, Middle) 2. Home Mailing Address (Number, Street, City, State, Zip Code) mi.

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