Get DoL LS-208 2021-2024

Please be sure to include the OWCP Case Number. For further instructions please see the reverse side of this form. Form LS-208 Rev. May 2015 A claim may be filed within one year after the injury or death 33 U.S.C. Notice of Final Payment or Suspension of Compensation Payments Print U*S* Department of Labor Office of Workers Compensation Programs Reset INSTRUCTIONS This notice must be filed with the District Director at the address in 3 a within 16 days after compensation has been stopped or suspended* A copy of the completed form must be mailed to the claimant and the claimant s representative. Use of this form is mandatory. Failure to timely file this form shall result in assessment of a penalty as outlined in 20 CFR 702. 236. This form is to be used to report disability or death compensation payments as well as other statutory payments. The information will be used to verify the sufficiency of compensation paid under the Act. 3. Name and address of Employee or other beneficiary Type or print Expires 05/31/2018 1. OWCP No* 2. Carrier s No* 3a* Central Mail Receipt site Division of Longshore and Harbor Workers Compensation 400 West Bay Street Suite 63A Box 28 Jacksonville FL 32202 Place within brackets United States or Upload directly to the case file at https //seaportal*dol-esa*gov 4. Name of employer 6. Date of Injury OMB No* 1240-0041 5. Address of employer 7. Date employee first lost pay because of injury 7a* Date first check issued 8. Date physician found employee able to return to work 10. Was compensation paid at the maximum rate Yes No multiplied by 2/3 Compensation rate Average weekly wage 11. State reason or reasons for termination or suspension of payments 12. Date last payment made 13. Date of this notice TYPE OF DISABILITY a Temporary total ENTER ALL PAYMENTS MADE ON ACCOUNT OF DISABILITY FROM THROUGH AMOUNT PAID Mo. day yr. PER WEEK b c d NUMBER OF WEEKS PAID e TOTAL f Temporary partial Permanent partial non-schedule Percent Part of body Permanent total TOTAL PAID Attach continuation sheet to show additional periods rates and amounts BENEFICIARY S NAME AND DATE OF BIRTH ENTER OTHER PAYMENTS a* Section 8 i Settlement 1 Compensation 2 Medical benefits e. Attorney fees b. Compensation for late payment per Sec* 14 e or f f* Funeral Expenses c* Interest g. Sec* 44 c 1 payment to the Special Fund d. Disfigurement h. Commutation As verified by the signature below this form was mailed to the claimant and claimant s representative. 17. Name of insurance carrier or self-insured employer and claim administrator a* Address and phone number of person whose name is shown in Box 18 18. Signature of person authorized to sign for employer or carrier 19. Name and Title of person whose signature appears in Box 18 EMPLOYEEPLEASE READ CAREFULLY Any claim for compensation to be valid must be filed IN WRITING with the District Director OWCP WITHIN ONE YEAR after the date of injury or date of last payment of compensation* If you have any impairment of the body serious disfigurement or other disability from the injury which may handicap you in securing or maintaining employment you should submit a claim to the U* S* Department of Labor as shown in 3a above.