Form LS-202 Employer's Firt Report of Injury or Occupational Illness

Employer's First Report of Injury
or Occupational Illness
(See instructions on reverse - Leave Items 1 and 2 blank)
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U.S. Department of Labor

Employment Standards Administration
Office of Workers' Compensation Programs
OMB No. 1215-0031

Submit
2. Carrier's No.

1. OWCP No.

3. Date and Time of Accident
(mm/dd/yyyy) * (hh:mm am/pm)
5. Employee's Address (No., street, city, state, ZIP, country) *

4. Name of Injured/Deceased Employee (Type or print - first, M.I., last)
M.I. Last Name *
Telephone
First Name *

street:
city:

6. Injury is Reported Under the Following
Act (Mark one)

?

7. Indicate Where Injury Occurred
(Longshore Act only) (Mark one)

Longshore and Harbor Workers A
Compensation Act

B

Defense Base Act
Nonappropriated Fund Instrumentalities Act
Outer Continental Shelf Lands
Act

D

Aboard Vessel or Over Navigable Waters

B

Pier/Wharf

C

Dry Dock

D

Marine Terminal

E

Building Way

F

Marine Railway

G

Other Adjoining Area

zip:

ctry:

9. Date of Birth
(mm/dd/yyyy)

*

*

M

A

C

st:

8. Sex

F

10. Social Security No. (Required by Law) *

11. Did Injury Cause Death?
Yes - If yes, skip to 16
No
12. Did Injury Cause Loss of Time Beyond
Day or Shift of Accident?

No
13. Date and Hour Employee
First Lost Time
Because of Injury

Date
(mm/dd/yyyy)

14. Did Employee Stop Work
immediately?

Yes 15. Date&hour empl returned to work 16. Was Employee Doing Usual Work When
(mm/dd/yyyy)
(hh:mm am/pm)
Injured/Killed? (if no, explain in Item 26)
No

17. Did Injury/Death Occur on
Employer's Premises?

Yes 18. Dept. in Which Employee Normally Works(ed)

Time
(hh:mm am/pm)

Yes
No

19. Occupation

No

20. Date and Hour Pay Stopped
(mm/dd/yyyy)
(hh:mm am/pm)

21. Which Days Usually Worked Per Week?
S M
T W T
(Mark (X) days)

23. Wages or Earnings (include
overtime, allowances, etc.)

24. Exact Place Where Accident Occurred (See instructions
on reverse). This item should specify area if accident
was in maritime employment and occurred in area
?
adjoining navigable waters. *

a. Hourly

Yes

F

S

22. Date employer or foreman first knew of accident.
(mm/dd/yyyy) * (hh:mm am/pm)
25. How was Knowledge of Accident or
Occupational Illness Gained?

b. Daily
c. Weekly
d. Yearly
26. Describe in full how the accident occurred (Relate the events which resulted in the injury or occupational disease. Tell what the
injured was doing at the time of the accident. Tell what happened and how it happened. Name any objects or substances involved and tell
how they were involved. Give full details on all factors which led or contributed to the accident.)

27. Nature of Injury (Name part of
body affected - fractured left leg,
bruised right thumb, etc.) If there
was amputation of a member of the
body, describe.

28. Has Medical Attention
Been Authorized?

Enter Date of Authorization
Yes 29. (mm/dd/yyyy)
No

Name
32. Physician

30. Was First Treating
Yes 31. Has Insurance
Physician Chosen
Carrier Been
No
Notified?
by Employee?
Address - Enter Number, Street, City, State, ZIP Code

Yes
No

33. Hospital
34. Insurance
Carrier *

*

35. Employer

*

*
37. Signature of Person Authorized to Sign for Employer
Signature

36. Employer's
Business
38. Official Title of Person Signing This Report

*

Name of Person Signing This Report

*

39. Date of This Report (mm/dd/yyyy)
04/04/2007
Form LS-202
Rev. Oct. 1998

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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. 930(a).
File form within 10 days from the date of injury or death or
from the date the employer first has knowledge of an injury or
death. Under the law all medical treatment and compensation
must be furnished by the employer or its insurance company.
Treatment must be by a physician chosen by the employee.

unless the physician is on a list of physicians currently not
authorized by the Department of Labor to render medical
care under the Act. Compensation payments become due and
are payable on the 14th day after the employer first has knowledge
of the injury or death. Penalties may be charged for failure to
comply with provisions of the law. The information will be used to
determine entitlement to benefits. Persons are not required to
respond to this collection of information unless it displays
a currently valid OMB control number.

REPORTABLE INJURY – Any accidental injury which causes loss of one or more shifts of work or death allegedly arising out of and
in the course of employment, including any occupational disease or infection believed or alleged to have arisen naturally out of
such employment, or as a natural or unavoidable result from an accidental injury. If the employer controverts the right to
compensation it must also file a notice of controversion with the District Director within 14 days after it has knowledge of the
alleged injury or death.

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Item 6 – A. Longshore and Harbor Workers’ Compensation Act
covers employees injured while engaged in maritime
employment upon the navigable waters of the United States
(including any adjoining pier, wharf, dry dock, terminal,
building way, marine railway, or other adjoining area
customarily used by an employer in loading, unloading,
repairing, or building a vessel); - employees injured upon the
navigable waters of the United States and other described
areas who at the time of injury were engaged in maritime
employment and are not otherwise specifically excluded under
the Act (33 U.S.C. 902).
B. Defense Base Act covers any employment (1) at military,
air, and naval bases acquired by the United States from foreign
countries; (2) on lands occupied or used by the United States
for military or naval purposes outside the continental limits of
the United States; (3) upon any public work in any Territory or
possession outside the continental United States under a
contract of a contractor with the United States; (4) under a
contract entered into with the United States where such
contract is to be performed outside the continental United
States and at places not within the areas described in (1), (2),
and (3) above for the purpose of engaging in public work; (5)
under certain contracts approved and financed by the United
States under the Mutual Security Act of 1954, as amended; and
(6) in the service of American employers providing welfare or
similar services for the benefit of the Armed Forces outside the
Continental United States.

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Item 24 – “Exact place where accident occurred” requires the
nearest street address, city and town. In addition O

If on a vessel,
Give place on vessel where injury happened (Deck, hold,
tweendeck, engine room, etc.) Name of vessel

O

If either on an adjoining pier, wharf, dry dock, terminal
building way, marine railway, or other area customarily
used in loading, unloading, repairing, or building a
vessel
Name or number of pier, dry dock, marine railway, etc.
Name of the terminal or shipyard
Nearest street address – City and State

O

If on a military or Defense Base,
Give exact place on base where injury happened
Name of base
Location of base – town or country

O

If on the Outer Continental Shelf,
Give drilling site and block number
Area name (e.g. West Delta Area)
Federal Lease Number, State Lease Number
Distance from and name of nearest land,
name of State

C.
Nonappropriated Fund Instrumentalities Act covers
employees of nonappropriated fund instrumentalities of the
Armed forces, e.g., post exchanges, motion picture service,
etc.
D. Outer Continental Shelf Lands Act covers employees of
private employers engaged in operations conducted on the
Outer Continental Shelf for the purpose of exploring for,
developing, removing, or transporting by pipeline the natural
resources of submerged lands.
NOTE: FILING THIS FORM DOES NOT CONSTITUTE AN ADMISSION OF LIABILITY UNDER THE COMPENSATION ACT. Any
employer, insurance carrier, or self-insured employer who knowingly and willfully fails to submit this report when
required or knowingly or willfully makes a false statement or misrepresentation in this report shall be subject to a civil
penalty not to exceed $10,000 for each such failure, refusal, false statement, or misrepresentation. [33 U.S.C.930(e)] This
report shall not be evidence of any fact stated herein in any proceeding in respect to any such injury or death on
account of which the report is made. [33 U.S.C. 930(c)]

Public Burden Statement
We estimate that it will take an average of 15 minutes to complete this collection of information, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If
you have any comments regarding these estimates or any other aspect of this collection of information, including suggestions for reducing this
burden, send them to the U. S. Department of Labor, Division of Longshore and Harbor Workers Compensation, 200 Constitution Avenue, N.W.,
Room C-4315, Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE