Get Form Ls 201

Filling out Form Ls 201 is an essential step for employees reporting injuries or illnesses covered under the Longshore and Harbor Workers' Compensation Act. This guide provides clear, step-by-step instructions to assist you in completing the form online, ensuring that you receive the benefits you are entitled to.

Follow the steps to fill out the Form Ls 201 online

1. Click the ‘Get Form’ button to access the document and open it in your preferred online editor.
2. Fill in the employee's name in the designated section, ensuring you provide the last name, first name, and middle name, if applicable.
3. Complete the home mailing address field. Include the number, street, city, state, and zip code.
4. Enter the employee's date of birth using the format of month, day, and year.
5. Select the employee's sex by marking 'Male' or 'Female'.
6. Input the home telephone number complete with the area code.
7. Provide the employee's Social Security Number as this is required by law.
8. Specify the employee's job title in the corresponding section.
9. Fill out the name and address of the employer, including the number, street, city, state, and zip code.
10. Record the date of injury in the required format of month, day, year.
11. Indicate the hour when the injury occurred.
12. Describe the place where the injury took place.
13. Specify whether the employee stopped working due to the injury by marking 'Yes' or 'No'.
14. If applicable, provide the date the employee stopped working due to the injury.
15. Detail the cause of the injury by explaining how it was related to employment.
16. Indicate the effects of the injury, including the part of the body affected or indicating if death occurred.
17. If the employee is reporting an injury, they should sign in item 17, confirming their request for compensation and medical care.
18. If reporting death, the claimant or their representative should sign in item 18, requesting death benefits for survivors.
19. Record the date on which the notice is being delivered to the employer and confirm the process of sending a copy to the District Director.
20. Finally, ensure all information is correct, save changes, and opt to download or print the completed form for submission.

Complete your Form Ls 201 online now to ensure you receive the benefits you deserve.