U.S. Department of Labor Report of Injury Experience of Insurance Carrier or Self-Insured Employer Employment Standards Administration Office of Workers' Compensation Programs Division of Longshore and Harbor Workers' Compensation This report is to be used to list all open cases as of the date of the report. The information provided will be used to determine the adequacy of a self-insurer's security deposit. Submission of the information is mandatory (20 CFR 703.310). Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Insurance Carrier or Self-Insured Employer's Name Reporting Period From: Insurance Carrier/Self-Insured Employer Address (Number and Street, City, State and ZIP code) Social Security OWCP Case Number Name of Injured Employee Date of Injury Nature of Injury Use Abbreviations - Fx, spr, etc. Amount of Benefits Paid (a) (b) (c) (d) (e) (f) Estimate of Future Compensation Payments (g) OMB No.: 1215-0160 List All Open Cases Cases as of the Date of This Report Estimate of Future Mediical Payments (Disability cases only) Estimate of Total Future Compensation Payments (g & h) (h) (i) Date of Report Check Check OWCP Third Fatal Number Party Cases Verification Cases (Leave Blank) (j) (k) (l) Public Burden Statement We estimate that it will take an average of 60 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, Room C4315, 200 Constitution Avenue, N.W., Washington, D.C. 20210. Form LS-274, Rev. Jan. 2004 American LegalNet, Inc. www.USCourtForms.com Page 2, Form LS-274 OMB No. 1215-0160 PRIVACY ACT OF 1974 NOTICE In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 522a), you are hereby notified that: (1) The Longshore and Harbor Workers' Compensation Act, as amended and extended (33 U.S.C. 901 et seq.) is administered by the Office of Workers' Compensation Programs of the U.S. Department of Labor. In accordance with this responsibility, the Office receives and maintains personal information on claimants and their immediate families. (2) The information will be used to determine eligibility for the amount of benefits payable under the Act. (3) The information may be used by other agencies or persons in handling matters relating, directly or indirectly, to the subject matter of the claim, so long as such agencies or persons have received the consent of the individual claimant; or have compiled with the provisions of 20 CFR 702. (4) Furnishing all requested information will facilitate the claims adjudication process, and the effects of not providing all or any part of the requested information may delay the process, or result in an unfavorable decision or a reduced level of benefits. IMPORTANT NOTICE Section 31(a) (1) of the Longshore and Harbor Workers' Compensation Act, 33 U.S. C. 931(a) (1), provides as follows: Any claimant or representative of a claimant who knowingly and willfully makes a false statement or representation for the purpose of obtaining a benefit or payment under this Act shall be guilty of a felony, and on conviction thereof shall be punished by a fine not to exceed $10,000, by imprisonment not to exceed five years, or by both. INSTRUCTIONS: All carriers and self-insured employers are required to submit this report on an annual basis, as required by 20 CFR 703.310 1. A separate report must be submitted for each act, each state and for each year of payments. 2. Show the carrier/self insurance authorization number on each report. 3. If the company has subsidiaries, separate reports for each state, each act and each year of payments must be submitted for each subsidiary. 4. Each report must be listed chronologically by accident date and include: • Column a - the claimant's social security number; • Column b - the OWCP case number; • Column c - the name of the injured employee; • Column d - the date of injury; • Column e - the nature of injury; • Column f - the amount of compensation and medical payments paid through the reporting year; • Column g - the estimate of future compensation benefit payments; • Column h - the estimate of future medical benefit payments; • Column i - the estimate total compensation and medical payments expected to be paid in the future; • Column j - a checkmark if the case is a fatal case; and • Column k - a checkmark if the case is a third party case. 5. Each report should reflect a total for all estimated future payments for that act, state and reporting year. 6. A separate report showing the grand totals for all states by act should also be submitted. 7. All submitted reports must include a separate notarized statement on company letter, signed by a corporate officer attesting to the completeness and accuracy of the information reported. This statement must also indicate the name and telephone number of the person to be contacted in the event there are questions. The report should be addressed as follows: US Department of Labor ESA/OWCP/DLHWC, Room C-4315 200 Constitution Avenue, NW Washington, DC 20210 Attn: Michael Niss, Director, DLHWC Failure to submit the complete report as outlined in these instructions may result in termination of your authorization to write insurance or be self-insured under the Act(s). This insurance or self-insurance authorization cannot be transferred or assigned. Any change involving the corporate name, structure, ownership, organization, etc., may affect the insurance carrier/selfinsurance authority and must be brought to the attention of this Office prior to the effective date of the event. For further information and or assistance, please contact the Insurance Branch at 202 693-0039. American LegalNet, Inc. www.USCourtForms.com