LS-513 proposed Report of Payments

U.S. DEPARTMENT OF LABOR
REPORT OF PAYMENTS
Employment Standards Administration
Office of Workers’ Compensation Programs
www.dol.gov/esa./owcp/dlhwc/index,htm
OMB No. 1215-0160
This report is required by law, (33 U.S.C.901 et seq.). Failure to report can result in termination of authorization to provide
coverage. Show number of cases and all payments made during the calendar year 20___ under the following acts:
Compensation
Act

Authorization
Number

No. of Cases
Compensated

Compensation
Payments

Medical
Payments

Longshore
Defense Base
Nonappropriated Fund
Outer Continental Shelf
District of Columbia
TOTAL $
Enter “None” in spaces where
no payment was made

I certify that I am an officer or official of the insurance company or self-insurer named above and am duly authorized to file
this report, and that I have carefully examined the facts contained herein and they are true to the best of my knowledge.
(Any person who knowingly and willfully makes a false statement of conceals a material fact shall be fined not more than
$10,000 or imprisoned not more than five years, or both (18 U.S.C. 1001)

_______________________________________________
Signature

____________________________________________
Printed name

_______________________________________________
Title (Print or Type

____________________________________________
Date

Public Burden Statement
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the Office of IRM Policy, Department of Labor, Room N-1301, 200 Constitution Avenue, N.W.,
Washington, DC 20210; and to the Office of Management and Budget, Paperwork Reduction Project (1215-0160), Washington, DC
20503. In accordance with the Paperwork Reduction Act of 1995, persons are not required to respond to this collection of information
unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is 1215-0160.
DO NOT SEND THE COMPLETED FORM TO EITHER OF THESE OFFICES

Form LS-513
Rev. April 2009