Employer's First Report of Injury or Occupational Illness (See instructions on reverse - Leave Items 1 and 2 blank) U.S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs OMB No. 1215-0031 2. Carrier's No. 1. OWCP No. 3. Date and Time of Accident (mm/dd/yyyy) (hh:mm am/pm) 5. Employee's Address (No., street, city, state, ZIP, country) 4. Name of Injured/Deceased Employee (Type or print - first, M.I., last) M.I. Last Name Telephone First Name street: city: 6. Injury is Reported Under the Following Act (Mark one) ? 7. Indicate Where Injury Occurred (Longshore Act only) (Mark one) Longshore and Harbor Workers A Compensation Act B Defense Base Act Aboard Vessel or Over Navigable Waters Marine Terminal Building Way F Marine Railway G Outer Continental Shelf Lands Act D E Nonappropriated Fund Instrumentalities Act Dry Dock Other Adjoining Area ctry: F 10. Social Security No. (Required by Law) Pier/Wharf C D B zip: 9. Date of Birth (mm/dd/yyyy) M A C st: 8. Sex 11. Did Injury Cause Death? Yes - If yes, skip to 16 No 12. Did Injury Cause Loss of Time Beyond Day or Shift of Accident? Yes No Date (mm/dd/yyyy) Time (hh:mm am/pm) 14. Did Employee Stop Work immediately? Yes 15. Date&hour empl returned to work 16. Was Employee Doing Usual Work When (hh:mm am/pm) (mm/dd/yyyy) Injured/Killed? (if no, explain in Item 26) No Yes 17. Did Injury/Death Occur on Employer's Premises? Yes 18. Dept. in Which Employee Normally Works(ed) 13. Date and Hour Employee First Lost Time Because of Injury 19. Occupation No 20. Date and Hour Pay Stopped (mm/dd/yyyy) (hh:mm am/pm) 21. Which Days Usually Worked Per Week? S M T W T (Mark (X) days) 23. Wages or Earnings (include overtime, allowances, etc.) 24. Exact Place Where Accident Occurred (See instructions on reverse). This item should specify area if accident was in maritime employment and occurred in area ? adjoining navigable waters. a. Hourly No F S 22. Date employer or foreman first knew of accident. (mm/dd/yyyy) (hh:mm am/pm) 25. How was Knowledge of Accident or Occupational Illness Gained? b. Daily c. Weekly d. Yearly 26. Describe in full how the accident occurred (Relate the events which resulted in the injury or occupational disease. Tell what the injured was doing at the time of the accident. Tell what happened and how it happened. Name any objects or substances involved and tell how they were involved. Give full details on all factors which led or contributed to the accident.) 27. Nature of Injury (Name part of body affected - fractured left leg, bruised right thumb, etc.) If there was amputation of a member of the body, describe. 28. Has Medical Attention Been Authorized? Enter Date Yes 29. (mm/dd/yyyy) of Authorization No Name 32. Physician 30. Was First Treating Yes 31. Has Insurance Physician Chosen Carrier Been No Notified? by Employee? Address - Enter Number, Street, City, State, ZIP Code Yes No 33. Hospital 34. Insurance Carrier 35. Employer 36. Employer's Business 37. Signature of Person Authorized to Sign for Employer 38. Official Title of Person Signing This Report Name of Person Signing This Report 39. Date of This Report (mm/dd/yyyy) American LegalNet, Inc. www.USCourtForms.com Form LS-202 Rev. Oct. 1998 Go to Form This report is to be filed in duplicate with the District Director in the appropriate district office of the Office of Workers’ Compensation Programs and is required by 33 U.S.C. 930(a). File form within 10 days from the date of injury or death or from the date the employer first has knowledge of an injury or death. Under the law all medical treatment and compensation must be furnished by the employer or its insurance company. Treatment must be by a physician chosen by the employee. unless the physician is on a list of physicians currently not authorized by the Department of Labor to render medical care under the Act. Compensation payments become due and are payable on the 14th day after the employer first has knowledge of the injury or death. Penalties may be charged for failure to comply with provisions of the law. The information will be used to determine entitlement to benefits. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. REPORTABLE INJURY – Any accidental injury which causes loss of one or more shifts of work or death allegedly arising out of and in the course of employment, including any occupational disease or infection believed or alleged to have arisen naturally out of such employment, or as a natural or unavoidable result from an accidental injury. If the employer controverts the right to compensation it must also file a notice of controversion with the District Director within 14 days after it has knowledge of the alleged injury or death. < Item 6 – A. Longshore and Harbor Workers’ Compensation Act covers employees injured while engaged in maritime employment upon the navigable waters of the United States (including any adjoining pier, wharf, dry dock, terminal, building way, marine railway, or other adjoining area customarily used by an employer in loading, unloading, repairing, or building a vessel); - employees injured upon the navigable waters of the United States and other described areas who at the time of injury were engaged in maritime employment and are not otherwise specifically excluded under the Act (33 U.S.C. 902). < Item 24 – “Exact place where accident occurred” requires the nearest street address, city and town. In addition - B. Defense Base Act covers any employment (1) at military, air, and naval bases acquired by the United States from foreign countries; (2) on lands occupied or used by the United States for military or naval purposes outside the continental limits of the United States; (3) upon any public work in any Territory or possession outside the continental United States under a contract of a contractor with the United States; (4) under a contract entered into with the United States where such contract is to be performed outside the continental United States and at places not within the areas described in (1), (2), and (3) above for the purpose of engaging in public work; (5) under certain contracts approved and financed by the United States under the Mutual Security Act of 1954, as amended; and (6) in the service of American employers providing welfare or similar services for the benefit of the Armed Forces outside the Continental United States. If on a vessel, Give place on vessel where injury happened (Deck, hold, tweendeck, engine room, etc.) Name of vessel If either on an adjoining pier, wharf, dry dock, terminal building way, marine railway, or other area customarily used in loading, unloading, repairing, or building a vessel Name or number of pier, dry dock, marine railway, etc. Name of the terminal or shipyard Nearest street address – City and State If on a military or Defense Base, Give exact place on base where injury happened Name of base Location of base – town or country If on the Outer Continental Shelf, Give drilling site and block number Area name (e.g. West Delta Area) Federal Lease Number, State Lease Number Distance from and name of nearest land, name of State C. Nonappropriated Fund Instrumentalities Act covers employees of nonappropriated fund instrumentalities of the Armed forces, e.g., post exchanges, motion picture service, etc. D. Outer Continental Shelf Lands Act covers employees of private employers engaged in operations conducted on the Outer Continental Shelf for the purpose of exploring for, developing, removing, or transporting by pipeline the natural resources of submerged lands. NOTE: FILING THIS FORM DOES NOT CONSTITUTE AN ADMISSION OF LIABILITY UNDER THE COMPENSATION ACT. Any employer, insurance carrier, or self-insured employer who knowingly and willfully fails to submit this report when required or knowingly or willfully makes a false statement or misrepresentation in this report shall be subject to a civil penalty not to exceed $10,000 for each such failure, refusal, false statement, or misrepresentation. [33 U.S.C.930(e)] This report shall not be evidence of any fact stated herein in any proceeding in respect to any such injury or death on account of which the report is made. [33 U.S.C. 930(c)] Public Burden Statement We estimate that it will take an average of 15 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the U. S. Department of Labor, Division of Longshore and Harbor Workers Compensation, 200 Constitution Avenue, N.W., Room C-4315, Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE American LegalNet, Inc. www.USCourtForms.com