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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How to fill out the DoL LS-202 online
Filling out the Department of Labor LS-202 form is an essential step in reporting an injury or occupational illness in accordance with U.S. labor laws. This guide provides clear, step-by-step instructions to assist users in completing the form accurately and efficiently.
Follow the steps to fill out your DoL LS-202 form online.
- Press the ‘Get Form’ button to access the form and open it for editing. This initiates the process of online completion.
- Enter the OWCP number, if applicable. This number identifies the case in the Office of Workers' Compensation Programs.
- Fill in the carrier's number, which is provided by the insurance carrier covering the injury.
- Input the date and time of the accident in the specified format (mm/dd/yyyy). This is crucial for chronological records.
- Provide the name of the injured or deceased employee, including first name, middle initial, last name, and their telephone number.
- Complete the employee’s address, including the street number, city, state, ZIP code, and country.
- Indicate under which Act the injury is reported, marking the appropriate option (e.g., Longshore and Harbor Workers’ Compensation Act).
- Specify where the injury occurred by marking the relevant option related to maritime employment.
- Respond to questions regarding lost time due to the injury, including dates and hours lost, ensuring to mark ‘Yes’ or ‘No’ accurately.
- Detail the employee's occupation and specify the department they typically work in.
- Provide information about the employee’s working days and the nature of the injury, being as descriptive as possible.
- Elaborate on how the accident occurred in the designated section. Clarity and detail are important here.
- Indicate if medical attention was authorized and provide the name of the treating physician and hospital, if applicable.
- Fill in the insurance carrier's details and any other relevant information pertaining to the employer and their business.
- Complete the official title and phone number of the person signing the report and ensure to add their signature.
- Finally, save changes made to the document. You can download, print, or share the completed form as necessary.
Complete your LS-202 form online today to ensure timely processing of your injury report.
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