Get Dol Ls-210 2014-2025

The DoL LS-210 form is an essential document for reporting accidents or occupational illnesses involving employees. This guide will help you complete the form accurately and efficiently online.

Follow the steps to fill out the DoL LS-210 online.

1. Click the ‘Get Form’ button to access the form and open it in your editing tool.
2. Enter the OWCP number in the designated field. This number is unique to the injured employee's case and is crucial for processing the report.
3. Fill in the insurance carrier's number to ensure the correct entity is associated with the case.
4. Provide the name of the injured employee, including their first name, middle initial, and last name.
5. Indicate the date of the accident by selecting the appropriate month, day, and year from the calendar option.
6. Input the injured employee's complete address, including the number and street, city, state, and ZIP code.
7. Document the initial period of disability by noting the inclusive dates: starting from when the employee became disabled to when they returned to work.
8. If applicable, list any subsequent periods of disability, ensuring to specify inclusive dates for each.
9. Answer whether the employee received medical attention. If yes, include dates and the names and addresses of the medical providers.
10. Indicate whether the employee was treated by their choice of physician, marking the appropriate box.
11. State if Form LS-1 was provided to the employee when the injury was reported to your organization.
12. Fill in the name of the employer (business name) along with the employer's complete address.
13. Ensure that a person authorized to sign for the employer provides their signature in the designated area.
14. List the name, official title, and phone number of the person who signed the form.
15. Finally, input the date of the report, ensuring to use the correct month, day, and year when completing this field.

Complete your documents online today to ensure timely processing and compliance.