Follow the steps to successfully fill out and submit the DoL LS-210.

1. Click the ‘Get Form’ button to access the form and open it in your chosen online editor.
2. Fill in the first field with the name of the injured employee, including their first name, middle initial, and last name.
3. Indicate the date of the accident by selecting or entering the month, day, and year.
4. Provide the address of the injured employee, including the number and street, city, state, and ZIP code.
5. Enter the name and address of your insurance carrier, ensuring all necessary contact details are included.
6. Complete the initial period of disability section by filling in the start and end dates and the date the employee returned to work.
7. If applicable, detail any subsequent periods of disability, using inclusive dates for each section.
8. Respond to the question about medical attention received by checking 'Yes' or 'No'. Provide further details if applicable.
9. Indicate if the employee was treated by their choice of physician by selecting 'Yes' or 'No'.
10. Fill in the name of the employer and their address, ensuring accuracy.
11. Sign the form in the space provided to confirm submission by an authorized person.
12. Provide the name, official title, and phone number of the individual who signed the report.
13. Finally, record the date of the report considering the month, day, and year.
14. Once all fields are completed and reviewed, save any changes made to the document. You may then choose to download, print, or share the form as necessary.

Get started on completing your DoL LS-210 form online today.