Form LS-207 Notice of Controversion of Right to Compensation

Notice of Controversion of Right
to Compensation
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U.S. Department of Labor

Office of Workers' Compensation Programs
Longshore and Harbor Workers' Compensation

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OMB No. 1240-0042

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.

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

1. OWCP File No.

2. Employer File No.

due (33 USC 914(d), (e). If the right to compensation is controverted, this form should be submitted in

3. Carrier File No.

4. Claimant's Name and Address

5. Claim File or Injury Reported

triplicate to the District Director, and the reasons for such controversion should be fully stated in item 12.

name:
line 1:
line 2:

First Name

M.I.

Last Name

city:
state:

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

Under (check one)

country:
United States

zip:

7. Employer's Name, Address and Phone Number

city:
zip:

st:

st:

8. Carrier's Name, Address and Phone Number

city:
st:
phone:

OCS

DCWCA

NFIA

DBA

city:

cnty: United States

LHWCA

zip:

cnty: United States
9. Nature of Injury or Occupational Disease

zip:
country:

United States
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

15. Title

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

phone:

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 20 CFR 702.251. 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 collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
1240-0042. 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. November 2011