Payment Of Compensation Without Award U.S. Department of Labor (Longshore and Harbor Workers' Compensation Act, Office of Workers' Compensation Programs as extended) OMB No. 1240-0043 NOTE: This Notice is to be filed with the District Director not later than the same day that first payment is made. A copy should be sent to the payee(s) AND to their attorney (if represented). 1. OWCP No. FOR OFFICE USE 2. CARRIER'S No. 3. Name of injured person (First, middle, last - please print or type) 4. Address of injured person (Number, street, city, state and ZIP code) United States 6. Date disability began (Month, day, year) 5. Date of accident or first illness (Month, day, year) 7. Name of injured, or dependents of injured, to whom compensation will be paid 8. multiplied by 2/3 compensation rate $ Average weekly wage $ (Mark if maximum rate is being paid) 9. Compensation will be paid from - Enter month, day, year. Yes No 9a. For DBA cases only, is the employer continuing to pay the injured person's salary? Yes until notice is given that payment has been stopped or suspended No 9b. If so, are these salary continuation payments being made in lieu of compensation payments? I0. Date of first payment (Month, day, year.) Yes No 11. Has medical care and treatment been provided by a physician or hospital chosen by the injured person? (Mark appropriate box) Yes No 12. Name and address of employer (Name, number, street, city, state, ZIP code and country) United States 13. Name and address of insurance carrier and/or claim administrator(Name, number, street, city, state, ZIP code and country) United States 14. Authorized signature 15. Type or print title and name of person whose signature appears in item 14 Phone number 16. Date signed(mm-dd-yyyy) 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 10 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 (20CFR 702.317). 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, Room C4315, 200 Constitution Avenue, NW, Room C-4315, Washington, D.C. 20210, and reference the OMB Control Number. DO NOT SEND COMPLETED FORMS TO THIS OFFICE. Form LS-206 Rev. August 2011 American LegalNet, Inc. www.FormsWorkFlow.com