Form LS-207 Notice of Controversion of Right to Compensation

Notice of Controversion of Right
to Compensation
Print

U.S. Department of Labor

Reset

Employment Standards Administration
Office of Workers' Compensation Programs
Longshore and Harbor Workers' Compensation

Submit

OMB No. 1215-0023

This report is required to obtain or retain benefits and is authorized by law and regulation (33 USC 914(d), (e); 20 CFR 702.251).
Failure to report when controverting right to compensation can result in liability for 10 percent additional compensation.

1. OWCP File No.
Instructions: This form may be used by the employer/carrier to controvert the right to compensation.
33 USC 914(a) requires the employer to pay compensation promptly and without an award unless the
right to such compensation is controverted by the filing of this form. Failure either to pay each installment
of compensation, or controvert the right to such compensation, within fourteen days after it becomes due
may result in liability for additional compensation equal to ten percent of each installment not paid when
due (33 USC 914(d), (e). If the right to compensation is controverted, this form should be submitted in
triplicate to the District Director, and the reasons for such controversion should be fully stated in item 12.
4. Claimant's Name and Address *

M.I.

First Name

name:
line 1:
line 2:

2. Employer File No.
3. Carrier File No.
5. Claim File or Injury Reported
Under (check one) *

Last Name

city:
state:

country:

zip:

7. Employer's Name, Address and Phone Number *

6. Employee's Name and Address
if different from Claimant's

LHWCA

OCS

DCWCA

NFIA

DBA

city:

city:
zip:

st:

st:

cnty:

zip:

cnty:

8. Carrier's Name, Address and Phone Number *

9. Nature of Injury or Occupational Disease

city:

zip:
phone:

country:

10. Date of Injury (Month, Day, Year)

11. Date of Employer's First Knowledge of Injury (Month, Day, Year)

*

*

12. Right to compensation is controverted for the following reason(s) *

13. Authorized Signature *

14. Print Name and Phone Number

*

phone:

Signature
15. Title *

16. Date of this Notice (Month, Day, Year)

*

10/14/2008
17. (OWCP USE) A copy of this form was mailed to the claimant and/or representative

on

Initials
Public Burden Statement

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 522a) and the Paperwork Reduction Act of 1995, as amended. The
authority for requesting the following information is 20CFR702.251. Use of this form is optional, however furnishing the information is required in order to
obtain and/or retain benefits. 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 colection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
1215-0023. The time required to complete this information collection is estimated to average 15 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 U.S.
Department of Labor, Division of Longshore and Harbor Worker's Compensation, Room C4315, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
DO NOT SEND COMPLETED FORMS TO THIS OFFICE.
Form LS-207
Rev. June 1997