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Information To Gather to Help Answer 38 Questions on a Longshore & Harbor Workers LHWCA Claim Form

The LS-203 Form titled “Employee’s Claim for Compensation,” issued by the U.S. Department of Labor, Office of Workers’ Compensation Programs. This form, identified with OMB Control Number 1240-0014 and revised in November 2023 and Expires: 11/30/2026, is used by employees to file claims for compensation under various acts including the Longshore and Harbor Workers’ Compensation Act, Defense Base Act, Outer Continental Shelf Lands Act, and Nonappropriated Fund Instrumentalities Act.
The LS-203 provides a detailed structure ensures that the form collects essential information required for the efficient processing of workers’ compensation claims under various U.S. laws. It is designed to gather detailed personal, employment, and injury-related information to facilitate the accurate determination of benefits and legal compliance. There are 38 specific questions:
  1. OWCP No.: Assigned Office of Workers’ Compensation Programs number for the claim if one already been assigned
  2. Carrier’s No.: Insurance carrier’s number associated with the claim.
  3. Name of Person Making Claim: Full name of the claimant (first, middle initial, last).
  4. Date of Injury: Specific date on which the injury occurred.
  5. Claimant’s Address: Full residential address of the claimant.
  6. Marital Status: Marital status of the claimant, either married or single.
  7. Gender Identity: Claimant’s gender identity from provided options or an option to decline to answer.
  8. Date of Birth: Claimant’s date of birth.
  9. Social Security #: Mandatory field for the claimant’s Social Security Number.
    1. a. Nationality: The claimant is asked to specify their nationality. This information could be relevant for understanding jurisdictional and legal considerations, especially in cases involving international or immigrant workers.
  10. Did Injury Cause Loss of Time Beyond Day or Shift of Accident?: Yes/no question regarding time loss due to the injury.
  11. Date and Time of Accident: Exact date and time when the accident took place.
    1. a. Did You Stop Work Immediately?: This is a yes/no question designed to establish the immediate impact of the injury. It asks whether the claimant stopped working immediately after the accident, providing insights into the severity of the incident and its immediate effects on the claimant’s ability to continue working.
  12. Date and Hour Pay Stopped: When the claimant stopped receiving their regular pay due to the injury.
  13. Date and Hour You Returned to Work: Date and time when the claimant resumed work, if applicable.
  14. Occupation (Job Title): Job title of the claimant at the time of injury.
  15. Injured While Doing Regular Work?: Whether the injury occurred while performing regular job duties.
  16. Wages or Earnings When Injured: Weekly earnings and total earnings in the year immediately before the injury.
  17. Has 3rd Party or Other Claim Been Made Because of This Injury?: Information on whether any third-party claims have been made due to the injury.
  18. Number of Years You Worked for This Employer: Duration of employment with the current employer.
  19. Number of Days Usually Worked Per Week: Average number of days worked per week.
  20. Name of Supervisor at Time of Accident: Supervisor’s name at the time of the injury.
  21. Earliest Date Supervisor or Employer Knew of Accident: When the employer or supervisor first became aware of the accident.
  22. Were You Employed Elsewhere During the Week Injured?: Employment status elsewhere during the week of the injury.
  23. Exact Place Where Accident Occurred: This section requires a detailed description of the specific location where the accident took place. The description should include:
    1. – Street Address: The precise street address where the accident occurred.
    2. – City, Town, Country: These details help pinpoint the location within broader geographical boundaries.
    3. – Additional specific details for certain types of claims:
      1. – For Longshore Claims: It is necessary to include the name of the vessel (if applicable), the pier, and the terminal where the incident occurred. These details are crucial for incidents related to maritime operations and help in identifying the exact maritime location, which can be significant in the context of maritime law.
      2. – For Defense Base Act (DBA) Claims: The name of the Department of Defense (DOD) facility or associated worksite needs to be specified, such as a base, Forward Operating Base (FOB), camp, etc. This provides clarity on the military or defense context of the accident, which is essential for claims under the DBA that covers civilian employees working on military bases or under a contract with the U.S. government for public works or for national defense. We have helped injured workers with Defense Base Act PTSD settlements and hearing loss. Contact us today.
  24. Describe in Full How the Accident Occurred: Comprehensive description of how the accident happened, including activities at the time of the accident, factors contributing to the accident, and involved objects or substances.
  25. Nature of Injury: Detailed description of the injury and affected body parts.
  26. Have You Received Medical Attention for This Injury?: Status of medical attention received, with provider details if applicable.
  27. Were You Treated by a Physician of Your Choice?: Indicates if the treatment was by a physician chosen by the claimant.
  28. Was Such Treatment Provided by Employer?: Whether the employer provided the medical treatment.
  29. Are You Still Disabled on Account of This Injury?: Current disability status due to the injury.
  30. Have You Worked During the Period of Disability?: Queries whether the claimant has engaged in any form of work during the period they were deemed disabled due to the injury.
  31. Have You Received Any Wages Since Becoming Disabled?: Seeks to know if the claimant has received any wages or compensation after they became disabled, which is important for adjusting potential benefits.
  32. Has Injury Resulted in Permanent Disability, Amputation or Serious Disfigurement?: Asks the claimant to disclose if the injury has led to permanent disability, amputation, or any serious disfigurement, which can significantly affect the type and duration of benefits received.
  33. Name of Employer (Individual or Firm Name): Requires the full legal name of the employer at the time of the accident.
  34. Nature of Employer’s Business: Describes the type of business or industry in which the employer operates, relevant for understanding the work environment and potential hazards.
  35. Address of Employer: The complete address of the employer, necessary for official communications and potential investigations.
  36. If Accident Occurred Outside the U.S., State Whether You Are a U.S. Citizen: This is particularly crucial for determining jurisdiction and the applicability of U.S. workers’ compensation laws if the accident occurred abroad.
  37. I Hereby Make Claim for Compensation Benefits: The claimant’s formal declaration of their intent to seek compensation benefits, which must be signed to process the claim.
  38. Date of This Claim: The date when the claim form is completed and submitted,
This detailed structure ensures that the form collects all essential information required for the efficient processing of workers’ compensation claims under various U.S. laws. It is designed to gather detailed personal, employment, and injury-related information to facilitate the accurate determination of benefits and legal compliance. The form MUST also be properly delivered to the US Department of Labor.

Contact a LS-203 Longshore Accident Lawyer Near You Today!

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If you have questions about completing form LS-203 or would like help filing your claim, contact us today.  Please be advised that you may be facing important legal deadlines, so don’t delay.
If you need help or have any questions, contact an experienced Longshore & Harbor Workers Comp lawyer near you at Lavis Law Firm at 866-289-2802 or submit your inquiry online. Please be advised that you may be facing important legal deadlines, so don’t delay. You can also visit us in person at our office.

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