LS-271 Application for Self-Insurance

Application for Self- Insurance

U.S. Department of Labor
Office of Workers' Compensation Programs

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OMB No. 1240-0014

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. No authorization for self-insurance will be approved unless a completed application form has been
received. [33 USC 932 (a)] [20 CFR 703.302]
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 Room S-3229, 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. [

Nonappropriated Fund Instrumentalities Act (5 USC 8171)

D. [

Outer Continental Shelf Lands Act (43 USC 1331)

2. Name and Address (principal office) of Applicant
name

EIN:

addr1

city

addr2

state

country
zip

US

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' Compensation 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

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

6. If this application is granted,
which do you elect to deposit
under this act?

c. Amount of Securities
[

Indemnity Bond

[

Securities

[

Letter of Credit
Form LS-271
Rev. March 2012

7. Do you maintain a medical facility 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

b. [

Deal through an insurance service
organization

(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, including what, if any, experience the organization has in Longshore.)

9.

ACCIDENT EXPERIENCE FOR PREVIOUS YEARS

YEAR

20

20

20

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

15. Name of Vice President

No

16. Name of Treasurer

17. Name of Secretary

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

Telephone

Signature
19. Name and Title

CORPORATE SEAL

20. Date of this application (mm/dd/yyyy)

DO NOT WRITE IN THE ITEMS BELOW
21. Date application received

22. OWCP Certification

PRIVACY ACT STATEMENT
The Privacy Act of 1974 as amended (5 U.S.C. 522a), section 901 of Title 33 to the US Code and 33 U.S.C. 932 (a) authorize collection of this information.
The purpose of this information is to determine an applicant's qualifications as a self-insurer under the Longshore and Harbor Workers' Compensation Act
(LWHCA). Completion of this form is not mandatory; however, failure to provide the information may result in the denial of request to self insure. 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.

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 3 hours 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 order to obtain and/or retain benefits. Send comments regarding this burden estimate
or any aspect of this collection of information, including suggestions for the reducing of this burden, to the U.S. Department of Labor, 200 Constitution
Avenue, NW, Room S-3229, Washington, D.C. 20210 and reference the OMB Control Number.