Approval of Compromise of Third U.S. Department of Labor Person Cause of Action Employment Standards Administration Office of Workers Compensation Programs Claimant OWCP Case No. V. Employer Insurance Carrier The above named employer and its insurance carrier, having liability for disability/death benefits under the Act in the above captioned case, and being advised that the claimant or representative above named has compromised the cause of action against third person(s), which arose out of the injury/death on in the case, in the gross amount of $ , and the net amount of $ dated herewith approves said compromise on the date shown below, pursuant to the provisions of Sec. 33(g) of the Longshore and Harbor Workers Compensation Act, 33 U.S.C. 933(g). Employer By Title Date Insurance Carrier By Title Date Claimant By Title Date Filed on in the Office of the District Director for the CompensationDistrict Date District Director This form, or a signed statement in lieu thereof containing language of the same intent, must be filed in the office of the District Director having jurisdiction of the subject injury or death within 30 days after compromise is made in order to insure that the employer shall be liable for compensati on as provided in section 33. Form LS-33 Rev. Jan . 2003 American LegalNet, Inc. www.USCourtForms.com