LS-271 proposed Application for Self-Insurance

Application for Self- Insurance

U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs

www.dol.gov.esa/owcp/dlhwc/index.htm
The applicant hereby requests that the Office of Workers' Compensation Programs grant permission for the Applicant to
become a self- insured employer in accordance with Section 32(a)(2) of the Longshore and Harbor Workers' Compensation Act
(33 USC 932 (a)(2)) in regard to the employer's obligations under the Compensation Act checked in item 1.

OMB No. 1215-0160

The declarations made in this application are for the purpose of enabling the Office of Workers' Compensation Programs to make a finding of facts as
to whether the Applicant possesses sufficient ability to render certain the payment of compensation, the furnishing of medical services and supplies to
injured employees, and the payment of compensation for death in accordance with the provisions of the Act checked in item 1.
The Applicant agrees to make and maintain a deposit of an indemnity bond with the Office OR a deposit of securities with a Federal Reserve Bank
(option to be indicated in Item 6) which shall be an amount determined by the Office and subject to the order of the Office. The Applicant further
agrees to abide by all the rules and regulations administered by the Office pertaining to the Longshore and Harbor Workers' Compensation Act (33
USC 901) or any of the extensions of the Act checked in item 1.
INSTRUCTIONS: All items are to be completed. If the answer to any item requires more space than provided, please attach a separate sheet and
identify the item you are answering. Information contained herein shall not be open to public inspection.
The Application must be accompanied by: (1) Copies of certified financial statements for the last three years. (2) Copy of the excess loss coverage
contract showing amount of net retention for any one accident and amount of maximum limit, (3) Loss information under the Act for the last five years,
showing the amount of paid and reserved losses. This should be in the form of a letter from the insurance carrier(s), showing the loss information for
each year, and (4) Statement showing amount of annual payroll under the Act by insurance classification.
The application should be mailed to: U.S. Department of Labor, Office of Workers' Compensation Programs, DLHWC, Washington, D.C. 20210.
1. Check only one of the Acts. If you wish to be self-insured under more than once Act, file a separate application for each.
A. [ ] Longshore and Harbor Workers' Compensation Act (33 USC 901)

C. [ ] Defense Base Act (42 USC 1651)

B. [ ] Nonapppropiated Fund Instrumentalities Act (5 USC 8171)

D. [ ] Outer Continental Shelf Lands Act (43 USC 1331)
EIN:

2. Name and Address (principal Office) of Applicant

3. NATURE OF BUSINESS - Describe briefly the general character of the operations performed and work done. If more than one class of work is
conducted, indicate division in payroll of each. Description should relate only to operations performed and work done under the Act checked in item 1.
Omit operations performed and work done under the State Compensation Act.

4. Information appearing in the columns below should relate to employees governed by the act checked in item 1 and for which self-insurance
authorization is requested. Omit employees governed by the State Workers' Compensaton Act. If you cannot so separate your employees between
the act checked in item 1 and the State Act, give information relating to all employees and indicate that the data covers all your employees.
Work Places and Locations

Estimated Number of Employees

a

b

No authorization for self- insurance will be approved unless a completed application form has been received. [33 USC 932 (a)] [20 CFR 703.302].

Public Burden Statement
The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended.
The authority for requesting the following information is 33 U.S.C. 932 (a). Use of this form is optional, however furnishing the information is required
in order to obtain authorization to self-insure. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor and a
person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 1215-0160. The time required to complete this information collection is estimated to average 2 hours 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 aspect of this collection of information, including suggestions for the
reducing this burden, to the U.S. Department of Labor, Division of Longshore and Harbor Workers' Compensation, Room C-4315, 200 Constitution
Avenue N.W., Washington, D.C. 20210.
Form LS-271
Rev. March 2009

5. If You Are Now Authorized As A Self- Insurer Under Any State Workers' Compensation Program, Give Amounts
Of Indemnity Bonds And Securities, And The States In Which Deposited.
a.

State

b. Amount of Indemnity Bond

c. Amount of Securities

6. If This Application Is Granted,
Which Do You Elect To Deposit
Under This Act?
[ ] Indemnity Bond
[ ] Securities

7. Do You Maintain A Hospital or Dispensary For The
Care of Injured Employees?
[ ] Yes (Describe equipment and service)
[ ] No (Specify arrangements you have made)
8. Which Do You Intend To Do?
a. [ ] Deal directly with employees in
compensation matters

(If you have checked "a", give name and address of persons responsible for claims handling, with brief
resume of their experience. If you have checked "b", give name and address of the organization, and
describe the arrangements)

b. [ ] Deal through an insurance service
organization
9.

ACCIDENT EXPERIENCE FOR PREVIOUS YEARS

YEAR
a. Number of deaths
b. Number of permanent total disability cases
c. Number of permanent partial disability cases (Schedule losses only)
d. Number of injuries not included in a, b, and c above, causing disability more
than three days
TOTALS
10. Date Applicant Was Incorporated
(mm/dd/yyyy)

11. Incorporated Under Laws of What State?

12. Date Applicant was established (if not a
corporation) (mm/dd/yyyy)

13. Did You Succeed Anyone?
[ ] Yes

[ ] No

(If "Yes", state whom)
14. Name of President

15. Name of Vice President

16. Name of Treasurer

17. Name of Secretary

18. I certify that I am an official of the above named applicant, duty authorized to file this application, that
I have carefully examined the foregoing statements, and the facts herein are true.

CORPORATE SEAL

Signature
19. Name and Title

20. Date of this application (mm/dd/yyyy)
DO NOT WRITE IN THE ITEMS BELOW

21. Date Application Received

22. OWCP Certification

PRIVACY ACT OF 1974 NOTICE
In accordance with the Privacy Act of 1974, as amended, (5 U.S.C. 522a), you are hereby notified that: (1) The Longshore and Harbor Workers'
Compensation Act (LHWCA), as amended and extended (33 U.S.C. 901 et seq.) is administered by the Office of Workers' Compensation Programs
of the U.S. Department of Labor which receives and maintains information on claimants and their immediate families. (2) Information which the Office
has will be used to determine eligibility for the amount of benefits under the LHWCA. (3) Information may be given to the employer which employed
the claimant at the time of injury, or to the insurance carrier or other entity which secured the employer's compensation liability. (4) Information may
be given to the physicians and other medical service providers for use in providing treatment or medical/vocational rehabilitation, making evaluations
and for other purposes relating to the medical management of the claim. (5) Information may be given to the Department of Labor's Office of
Administrative Law Judges (OALJ), or other person, board or organization, which is authorized or required to render decision with respect to the claim
or other matter arising in connection with the claim. (6) Information may be given to Federal, state and local agencies for law enforcement purposes,
to obtain information relevant to a decision under the LHWCA, to determine whether benefits are being and have been paid properly, and, where
appropiate, to pursue salary/administrative offset and debt collection actions required or permitted by law. (7) Failure to disclose all requested
information may delay the processing of the claim, the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.