Form LS-210 Employer's Supplementary Report of Accident or Occupatio

Employer's Supplementary Report of
Accident or Occupational Illness

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

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Notice: This Report should be filed promptly with the District Director in every case in which (1) Form LS-202 does not
show date injured employee returned to work, and (2) each time injured employee has returned to work and later
becomes disabled for work (33 U.S.C.930(b)) if the information is not already reported via Form LS-208. If the employee
was disabled for work more than 3 days, compensation payments should be reported on Form LS-208. Medical reports
must be sent to the District Director promptly following first treatment and thereafter while treatment continues.
Please type or print all information. (If additional space is needed, use back of form.) The information will be used to
determine entitlement to benefits. This report must be filed with the U.S. Department of Labor, Office of Workers’
Compensation Programs, Division of Federal Employees', Longshore and Harbor Workers' Compensation via
SEAPortal (https://seaportal.dol.gov) or Central Mail Receipt Site at: OWCP/DFELHWC, 400 West Bay Street, Room 63A,
Box 28, Jacksonville, FL 32202.

3. Name of injured employee (First, middle initial, last)

1. OWCP No.

2. Carrier's No.

4. Date of accident (Month, day, year)

5. Address of injured employee (Number and Street, City, State, ZIP code)

7. Initial Period of Disability
a. From (Month, day, year)

OMB No. 1240-0003
Expires: 02/29/2024

6. Name and address of your insurance carrier

(Use Inclusive Dates for a and b)
b. Through (Month, day, year)

c. Date returned to work (Month, day, year)

8. If this report covers a period of disability after the date shown in item 7c. state each subsequent period of disability. Use inclusive dates for
a. and b.
c. Date returned to work (Month, day, year)

b. Through (Month, day, year)

a. From (Month, day, year)

9. Did employee receive medical attention?
a.

Yes - Give dates, names and addresses of doctors and hospitals providing treatment.

10. Was employee treated by his or her choice of physician?
Yes

No

12. Name of employer

14. Signature of person authorized to sign
for employer

b.

No - Explain

11. Was form LS-1 given to employee when injury was reported to you?
Yes

No

13. Employer's address (Number and Street, City, State, ZIP code)

15. Name, official title and phone number of person signing

16. Date of report
(month, day, year)

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 order to obtain and/or retain benefits. (33 U.SC.930(b)). 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 S-3524, Washington, D.C. 20210, and reference the OMB Control Number.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
Form LS-210
Rev. Nov 2020

PRIVACY ACT OF 1974 NOTICE
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a) you are hereby notified that (1) the Longshore and Harbor Workers'
Compensation Act, as amended and extended (33 U.S.C. 901 et seq.) (LHWCA) is administered by the Office of Workers' Compensation Programs of
the U.S. Department of Labor, which receives and maintains personal information on claimants. (2) Information which the Office has will be used to
determine eligibility for the amount of benefits payable under the LHWCA. (3) Information may be given to the claimant or his/her representative. (4)
Information may be given to 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. (5) Information may be given to 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. (6) Information may be given to 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 or have been paid properly, and, where appropriate,
to pursuesalary/administrative offset and debt collection actions required or permitted by law.

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Form LS-210
Rev. Nov 2020