Form LS-272 Application to write Longshore Insurance

Application to write Longshore Insurance
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U.S. Department of Labor

Office of Workers' Compensation Programs
https://www.dol.gov/owcp/dlhwc/index.htm
OMB No. 1240-0014

The Applicant hereby requests that the Office of Worker's Compensation Programs grant permission for the Applicant to become authorized to write
insurance under the Longshore Act and its extensions in accordance with Section 32 of the Longshore and Harbor Workers' Compensation Act (33 USC
932) in regard to the insurance carrier's obligations under the Compensation Act checked in item 1.
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 securities with a Federal Reserve Bank or a Letter of Credit from an approved financial
institution, which shall be in 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 and/all required documentation must be submitted. 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) A letter signed by a corporate officer requesting authority to write coverage, including a statement of the
company's underwriting intentions, (2) A copy of the Statutory Annual Statement for the three most recent years, (3) A copy of the company's Articles of
Incorporation, (4) A copy of the Corporate by-laws, (5) A copy of the Certificate of Authority issued by a State insurance department granting authority to
write workers' compensation insurance, (6) A copy of the most recent examination report of the company by a State Insurance Commissioner's office,
(7) A copy of the most recent report of the company's NAIC's IRIS financial ratios, (8) A copy of the forms of policies and endorsements that will be
used.

The application should be mailed to: U.S. Department of Labor, Office of Workers' Compensation Programs,
DLHWC, Room S-3229, 200 Constitution Avenue, NW, Washington, DC 20210.
1. Check only one of the Acts. if you wish to be authorized under more than one 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

EIN:

3. If you are now authorized to write insurance under any state workers' compensation program, please advise of those states and the type of
coverage for which you are authorized.

4. Name of Company President

5. Name of Company Vice President

6. Name of Company Treasurer

7. Name of Company Secretary

8. 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.
Signature

(SEAL)

Telephone

9. Title
10. Date of This Application
DO NOT WRITE IN THE ITEMS BELOW

FORM LS-272

11. Date Application Received
12. OWCP Certification
No authorization for insurance will be approved unless a complete application form has been received. (33 USC 933) [20 CFR 703].

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 an insurance carrier 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 insure.

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 0MB 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 0MB Control Number.

FORM LS-272
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