Form LS-206 Payment of Compensation without Award

Payment Of Compensation Without Award

U.S. Department of Labor

(Longshore and Harbor Workers' Compensation Act,

Office of Workers' Compensation Programs

as extended)

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OMB No. 1240-0043

NOTE: This Notice is to be filed with the District Director not later than the same day that first
payment is made. A copy should be sent to the payee(s) AND to their attorney (if represented).
1. OWCP No.

Expires: XX-XX-XXXX

2. CARRIER'S No.

3. Name of injured person (First, middle, last - please print or type)

4. Address of injured person (Include number, street, city, state and zip code. Add country if not United States.)

United States
6. Date disability began (Month, day, year)

5. Date of accident or first illness (Month, day, year)

7. Name of injured, or dependents of injured, to whom compensation will be paid

8.

multiplied by 2/3 compensation rate $

Average weekly wage $

(Mark if maximum rate is being paid)

9a. Type of compensation paid.

Yes

No

9c. Is the employer continuing to pay the injured person's salary?
Yes

9b. Payment Begin Date (Month, day, year)

No

9d. If so, are these salary continuation payments being made in
lieu of compensation payments?

I0. Date of first payment (Month, day, year)

Yes

No

11. Has medical care and treatment been provided by a physician or hospital chosen by the injured person?
(Mark appropriate box)

Yes

No

12. Name and address of employer (Include name, number, street, city, state and zip code. Add country if not United States.)

United States
13. Name and address of insurance carrier and/or claim administrator (Include name, number, street, city, state and zip code. Add country
if not United States.)

United States
14. Authorized signature

15. Type or print title and name of person whose signature appears in item 14

Phone number

16. Date signed(mm-dd-yyyy)

Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection
displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes per response,
including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Use of this form is optional, however furnishing the information is required in accordance with
20CFR 702.234. Send comments regarding the burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the U.S. Department of Labor, 200 Constitution Avenue, NW, Room C-4319,
Washington, D.C. 20210, and reference the OMB Control Number.
DO NOT SEND COMPLETED FORMS TO THIS OFFICE.
Form LS-206
Rev. November 2014

PRIVACY ACT STATEMENT
The Privacy Act of 1974 as amended (5 U.S.C. 552a), section 901 of Title 33 to the US Code and 33 U.S.C. 914 (b)
and (c) authorize collection of this information. The purpose of this information is to determine the payment status
of a given case under the Longshore and Harbor Workers' Compensation Act (LHWCA). Completion of this form
is not mandatory; however, furnishing the information is required in accordance with 20FCR 702.234. Additional
disclosures of this information may be to: (1) 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. (2) 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. (3) the Department of Labor's Office of
Administrative Law Judges (OALJ), or other person, board or organization, which is authorized or required to
render decisions with respect to the claim or other matter arising in connection with the claim. (4) 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 appropriate, to pursue salary/
administrative offset and debt collection actions required or permitted by law. (5) 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.