Notice of Final Payment or Suspension of Compensation Payments U.S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs OMB No.: 1215-0024 INSTRUCTIONS: This notice must be filed with the District Director within 16 days after compensation has been stopped or suspended. Use of this form is mandatory. Failure to timely file this form shall result in 1. OWCP No. assessment of a penalty of $110.00. (33 U.S.C. 914(g)). This form is to be used to report disability or death compensation payments, as well as other statutory payments. The information will be used to verify the 2. Carrier's No. sufficiency of compensation paid under the Act. 3. Name and address of Employee or other beneficiary (Type or print) a. Address of the OWCP District Office where this form is filed Place within brackets CARRIER - Original (Copy 1) should be sent to the District Director. Copies 2, 3, 4 and 5 should be sent to the parties listed at the bottom of the form. Check the boxes at the bottom of the page to indicate parties copied. 5. Address of employer 4. Name of employer 6. Date of Iniury 7. Date employee first lost pay because of injury 9. Date employee returned to work 7a. Date of first payment of compensation 10. Was compensation paid at the maximum rate? Average weekly wage $ 11. State reason or reasons for termination or suspension of payments 8. Date physician found employee able to return to work Yes No multiplied by 2/3 = Compensation rate $ 12. Date last payment made 13. Date of this notice 14. TYPE OF DISABILITY a Temporary total Temporary total ENTER ALL PAYMENTS MADE ON ACCOUNT OF DISABILITY AMOUNT PAID FROM NUMBER OF THROUGH (Mo., day, yr.) (Mo., day, yr.) PER WEEK WEEKS PAID b c d e TOTAL f Temporary partial Permanent partial (Non-schedule) Permanent total Permanent partial Part of body Percent (Schedule loss, facial or other disfigurement) Attach continuation sheet to show additional periods, rates and amounts paid and enter total here. TOTAL PAID 15. ENTER ALL PAYMENTS MADE ON ACCOUNT OF DEATH a. Dependent name and date of birth b. AMOUNT c. OTHER PAYMENTS d. AMOUNT Funeral Expenses Sec. 44(c)(1) payment to the Special Fund (Attach continuation sheet) 16. a. Attorney fees b. Compensation for late payment per Sec. 14(e) or (f). c. Interest TOTAL (cols. b + d) ENTER OTHER PAYMENTS d. Sec. 8(i) Settlement e. Commutation 17. Name of insurance carrier or self-insured employer and claim administrator TOTAL (cols. a, b, c, d, e) a. Address and phone number of person whose name is shown in Box 19. 18. 19. Name and Title of person whose siqnature appears in Box 18 EMPLOYEEPLEASE READ CAREFULLY Any claim for compensation, to be valid, must be filed IN WRITING with the District Director, OWCP, VVITHIN ONE YEAR after the date of injury or date of last payment of compensation. lf you have serious disfigurement of the face, head, or neck or other normally exposed areas which may handicap you in securing or maintaining employment, or any impairment of the body or other disability from the injury for which you have not received compensation, you should inform the District Director. (Address in 3a above) Public Burden Statement The following statement is made in accordance with the Privacy Act of 1974 (5 USC 522a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the following information is 20 CFR 702.235. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is 1215-0024. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the U.S. Department of Labor, Division of Longshore and Harbor Workers' Compensation, Room C4315, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND COMPLETED FORMS TO THIS OFFICE 1 - District Director 4 - Employee 2 - Employer 5 - Employee's Representative 3 - Insurance Carrier Form LS-208 Rev. November 2008 The LS-208 dated June 1998 is being replaced by LS-208 dated November 2008. All previous copies will be destroyed or cannot be used. American LegalNet, Inc. www.FormsWorkflow.com