Loading
Form preview picture

Get ls 202 2020-2024

Date of This Report Form LS-202 Rev. Oct. 1998 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. Employer s First Report of Injury or Occupational Illness U*S* Department of Labor Employment Standards Administration Office of Workers Compensation Programs See instructions on reverse - Leave items 1 and 2 blank OMB No* 1215-0031 1. OWCP No* 2. Carrier s No* 3. Date and Time of Accident Mo. Day Yr. 4. Name of Injured/Deceased Employee Type or print - first M. I. last Hour AM PM 5. Employee s Address No* street city state ZIP code Telephone 6. Injury is Reported Under the Following Act Mark one 7. Indicate Where Injury Occurred Longshore Act only Mark one Building Way F Marine Railway G Outer Continental Shelf Lands Act D Marine Terminal E Nonappropriated Fund Instrumentalities Act C Dry Dock Other Adjoining Area 9. Date of Birth M 10. Social Security No* Required by Law 11. Did Injury Cause Death No Yes - If yes skip to 16 Day or Shift of Accident 13. Date and Hour Employee First Lost Time Because of Injury 14. Did Employee Stop Work Immediately Yes to Work 17. Did Injury/Death Occur on Employer s Premises 18. Dept. in Which Employee Normally Works ed 20. Date and Hour Pay Stopped 21. Which Days Usually Worked Per Week Mark X days S M T W T 23. Wages or Earnings Include overtime allowances etc* a* b. Hourly Daily c* d. Weekly Yearly 16. Was Employee Doing Usual Work When Injured/Killed If no explain in Item 26 19. Occupation 22. Date Employer or Foreman First Knew of Accident. 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. Pier/Wharf Defense Base Act Aboard Vessel or Over Navigable Waters Longshore and Harbor Workers Compensation Act B A 8. Sex 25. How was Knowledge of Accident or 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. Use additional sheet s if required and attach to this report 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 29. Enter Date of Authorization Name 30. Was First Treating Physician Chosen by Employee 31. Has Insurance Carrier Been Notified Address - Enter Number Street City State ZIP Code 32. Physician 33. Hospital 34. Insurance Carrier Federal Claims Unit 400 High Street SE Salem OR 97312-1000 35. Employer 36. Nature of Employer s Business 38. Official Title of Person Signing This Report 37. Signature of Person Authorized to Sign for Employer 39.

How It Works

accident injury report rating
4.8Satisfied
53 votes

Tips on how to fill out, edit and sign Zip code 202 online

How to fill out and sign Stop work form online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Experience all the benefits of submitting and completing forms on the internet. Using our platform completing DoL LS-202 only takes a couple of minutes. We make that achievable by offering you access to our full-fledged editor effective at changing/correcting a document?s original text, inserting unique fields, and putting your signature on.

Complete DoL LS-202 in a few moments by following the guidelines below:

  1. Choose the template you want from the library of legal form samples.
  2. Click on the Get form button to open the document and start editing.
  3. Fill in all the necessary boxes (they will be yellowish).
  4. The Signature Wizard will help you insert your electronic autograph as soon as you?ve finished imputing information.
  5. Insert the relevant date.
  6. Check the entire form to ensure you have filled in all the data and no changes are required.
  7. Hit Done and save the ecompleted template to the gadget.

Send your DoL LS-202 in an electronic form right after you finish completing it. Your information is well-protected, because we adhere to the most up-to-date security criteria. Join numerous happy clients who are already filling out legal forms from their houses.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing ls202

Our video guideline on how to fill in Form on the web will help you get the done task fast and efficiently. Don't bother, it takes only a couple of minutes from beginning to end.

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to ls 202 department of labor

  • injury worker report
  • employer report
  • employer injury report form
  • employer injury
  • accident worker report
  • accident injury
  • NONAPPROPRIATED
  • false
  • dba
  • 14th
  • empl
  • ctry
  • reportable
  • controverts
  • controversion
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.