LS-272instructions1

U.S. Department of Labor
Office of Workers’ Compensation Programs
Division of Longshore and
Harbor Workers’ Compensation
Washington, DC. 20210

REQUIREMENTS FOR AUTHORIZATION TO WRITE INSURANCE UNDER THE
LONGSHORE AND HARBOR WORKERS’COMPENSATION ACT AND/OR EXTENSIONS

The following information and instructions pertain to the
requirements for authorization to write insurance coverage under
the Longshore and Harbor Workers’ Compensation Act, and
extensions, the Defense Base Act, the Outer Continental Shelf
Lands Act, and the Nonappropriated Fund Instrumentalities Act.
INFORMATION AND MATERIAL WHICH MUST BE SUBMITTED along with the
completed Application Form:
(1)

A letter signed by a corporate officer requesting authority
to write coverage, including a statement of the company’s
underwriting intentions;

(2)

Most recent Statutory Annual Statement;

(3)

Copy of the company Articles of Incorporation;

(4)

Copy of the Corporate by-laws;

(5)

Copy of the Certificate of Authority issued by a State
insurance department granting authority to write workers’
compensation insurance;

(6)

Copy of the most recent examination report of the company
by a State Insurance Commissioner’s office;

(7)

Copy of the forms of policies and endorsements that will be
used;

(8)

The employer’s Identification Number (EIN) for each
applicant company. This should be furnished in the letter
signed by the corporate officer requesting the authority to
write coverage.
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(9)

A certification by the corporate officer stating that the
applicant company will perform the following:
1. Comply with all statutory and regulatory obligations,
including timely paying benefits and reporting information
[Sections 14(a) – (i) and Sections 30 (a) – (f)];
2. Utilize the informal dispute resolution mechanisms in
good faith by raising only issues that are ready for
resolution (i.e. all documentation is available) and sending
representatives who are both prepared and have authority to
resolve disputes;
3. Monitor and be held responsible for the performance in
items 1 – 2 above of their Third Party Administrator (TPA) or
other claims handlers acting on their behalf.
4. Respond to all penalty assessments in a timely manner.
[Sections 14(g), 30(e), and 48a];
5. Comply with data reporting and proof of coverage
processes including submitting each policy and endorsement
issued by the carrier to an employer and providing notice of
cancellation of a contract or policy of insurance to NCCI and
the applicable Independent Rating Bureaus.
6. Comply with annual Industry Notices for Advance and Final
Assessment for the Special Fund, posted on the DLHWC website
at: https://www.dol.gov/owcp/dlhwc/, to ensure timely payment
of Section 44 annual assessments.
To the greatest extent
possible, make payments to the Special fund through
Electronic Funds Transfers (EFTs).
7. Provide DLHWC with all information necessary, including
access to the carriers’ automated claims system, for DLHWC to
audit and confirm the accuracy of the carrier’s Report of
Payments (LS-513) and Report of Injury Experience (LS-274).

The statements of fact and supporting evidence shall be verified
by the notarized oath of the officer of the Applicant Company who
signs the application.
All business written under the Longshore and Harbor Workers’
Compensation Act, and its extensions, is subject to a security
deposit. In conjunction with this application, any insurance
carrier seeking to be exempt from depositing a security with the
Department of Labor must provide documentation that demonstrates
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that they have been awarded the highest financial ratings for both
the current rating year and the immediately preceding year by the
following rating organizations: the A. M. Best Company; Standard &
Poor's; and Fitch Ratings. NOTE: The highest available rating by
the A. M. Best Company is “A++”, Standard & Poors is “AAA” and
Fitch Ratings is “AAA”.
In any state where the state guarantee, or analogous, fund will
not fully protect all of the Longshore obligations of an insolvent
carrier, insurance carriers will be required to post security to
secure these obligations. Security must be in the form of a
surety bond issued by a surety company holding a Certificate of
Authority from the U.S. Treasury Department as acceptable sureties
on federal bonds, or a deposit of fully guaranteed negotiable
securities with a Federal Reserve Bank, or a bank issued letter of
credit from an approved bank.
This request will also be considered for waiver for all business
written through the National Reinsurance Pool operated by the
National Council on Compensation Insurance or any other assigned
risk pool providing full protection for Longshore Act benefits.
Finally, this waiver request will also be considered on receipt of
supporting documentation demonstrating that the company is a state
insurance fund or agency of the state government with the full
faith and credit of the state.
The request and supporting information should be sent to the
following address:
U.S. Department of Labor
OWCP/DLHWC, Room S-3229
200 Constitution Ave., NW
Washington, DC 20210
ATTN: Cheryl Jordan
For further information, please contact Cheryl Jordan at (202)
354-9634.

Director, Division of
Longshore and Harbor
Workers’ Compensation

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