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  • Dol Ls-202 2012

Get Dol Ls-202 2012

Date of This Report Form LS-202 Rev. Oct. 1998 This report is to be filed in duplicate with the District Director in the appropriate district office of the Office of Workers Compensation Programs and is required by 33 U.S.C. Employer s First Report of Injury or Occupational Illness U*S* Department of Labor Employment Standards Administration Office of Workers Compensation Programs See instructions on reverse - Leave items 1 and 2 blank OMB No* 1215-0031 1. OWCP No* 2. Carrier s No* 3. Date and Time of Accident Mo. Day Yr. 4. Name of Injured/Deceased Employee Type or print - first M. I. last Hour AM PM 5. Employee s Address No* street city state ZIP code Telephone 6. Injury is Reported Under the Following Act Mark one 7. Indicate Where Injury Occurred Longshore Act only Mark one Building Way F Marine Railway G Outer Continental Shelf Lands Act D Marine Terminal E Nonappropriated Fund Instrumentalities Act C Dry Dock Other Adjoining Area 9. Date of Birth M 10. Social Security No* Require....

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
DoL LS-202
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