Get DoL LS-203 2014-2023
print) MI. Last First 1. OWCP No. Telephone No. 5. Claimant's address (number, street, city, state, ZIP code) 2. Carrier's No. 4. Date of Injury city: state: line1: zip code: 6. Marital Status Married country: United States line2: 7. Sex Male Female 8. Date of Birth 11. Date and time of accident. (mm/dd/yyyy) 13. Date and hour you returned to work (mm/dd/yyyy) 9. Social Security # (Required by law) (hh:mm am/pm) 16. Wages or earnings when injured (include overtime allowances,.
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