Employer's First Report of Injury U.S.

Department of Labor
or Occupational Illness Office of Workers' Compensation Programs
(See instructions on reverse)
Print Reset OMB No. 1240-0003

1. OWCP No. 2. Carrier's No. 3. Date and Time of Accident

(mm/dd/yyyy) (hh:mm am/pm)

4. Name of injured/deceased employee (Type or print - first, M.I., last) 5. Employee's address (No., street, city, state, ZIP, country)
First Name M.I. Last Name Telephone Street:

City: St: Zip: Ctry:

6. Injury is reported under the following 7. Indicate where injury occurred 8. Sex 9. Date of birth
Act (Mark one) (Longshore Act only) (Mark one) (mm/dd/yyyy)
M F
Longshore and Harbor Workers'
A Compensation Act A Aboard vessel or over
navigable waters 10. Social security no. (Required 10a. Nationality (DBA only)
B Nonappropriated Fund Instru-
mentalities Act by law)
B Pier/Wharf

C Outer Continental Shelf Lands 11. Did injury cause death?

C Dry dock
Act No Yes - If yes, skip to 16
D Marine terminal
D Defense Base Act 12. Did injury cause loss of time beyond Yes
E Building way day or shift of accident?
1. Contracting Agency No
F Marine railway
2. Prime Contract # 13. Date and hour employee Date Time
G Other adjoining area first lost time (mm/dd/yyyy) (hh:mm am/pm)
3. Sub-Contract # because of injury

14. Did employee stop work Yes 15. Date & hour empl returned to work 16. Was employee doing usual work when Yes
immediately? (mm/dd/yyyy) (hh:mm am/pm) injured/killed? (if no, explain in Item 26)
No No
17. Did injury/death occur on Yes 18. Dept. in which employee normally works(ed) 19. Occupation
employer's premises?
No
20. Date and hour pay stopped 21. Which days usually worked per week? 22. Date employer or foreman first knew of accident.
(mm/dd/yyyy) (hh:mm am/pm) S M T W T F S (mm/dd/yyyy) (hh:mm am/pm)
(Mark (X) days)

23. Wages or earnings (include 24. Exact place where accident occurred (See instructions 25. How was knowledge of accident or
overtime, allowances, etc.) on reverse). This item should specify area if accident occupational illness gained?
was in maritime employment and occurred in area
a. Hourly adjoining navigable waters.
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.

28a. Has medical attention Yes 28b. LS-1 issued? 29. Enter date of 30. Was first treating Yes 31. Has insurance Yes
been authorized? authorization. physician chosen carrier been
No Yes No by employee? No notified? No
Name of: Address - Enter number, street, city, state, zip code
32. Physician

33. Hospital

34. Insurance
Carrier
35. Employer

36. Employer's 37. Signature of person authorized to sign for employer Phone number
Business

38. Official title and phone number of person signing this report Name of person signing this report 39. Date of this report
(mm/dd/yyyy)

Form LS-202
Rev. April 2012
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 Item 24 – “Exact place where accident occurred” requires the
covers employees injured while engaged in maritime nearest street address, city and town. In addition -
employment upon the navigable waters of the United States
(including any adjoining pier, wharf, dry dock, terminal, l If on a vessel,
building way, marine railway, or other adjoining area Give place on vessel where injury happened (Deck, hold,
customarily used by an employer in loading, unloading, tweendeck, engine room, etc.) Name of vessel
repairing, or building a vessel); - employees injured upon the
navigable waters of the United States and other described l If either on an adjoining pier, wharf, dry dock, terminal
areas who at the time of injury were engaged in maritime building way, marine railway, or other area customarily
employment and are not otherwise specifically excluded under used in loading, unloading, repairing, or building a
the Act (33 U.S.C. 902). vessel

B. Nonappropriated Fund Instrumentalities Act covers Name or number of pier, dry dock, marine railway, etc.
employees of nonappropriated fund instrumentalities of the Name of the terminal or shipyard
Armed forces, e.g., post exchanges, motion picture service, Nearest street address – City and State
etc.
l If injury or death is reported under the Defense Base
C. Outer Continental Shelf Lands Act covers employees of Act, give the name of the country where injury or death
private employers engaged in operations conducted on the occured.
Outer Continental Shelf for the purpose of exploring for,
developing, removing, or transporting by pipeline the natural
resources of submerged lands.
l If on the Outer Continental Shelf,
D. Defense Base Act covers any employment (1) at military,
air, and naval bases acquired by the United States from foreign Give drilling site and block number
countries; (2) on lands occupied or used by the United States Area name (e.g. West Delta Area)
for military or naval purposes outside the continental limits of Federal Lease Number, State Lease Number
the United States; (3) upon any public work in any Territory or Distance from and name of nearest land,
possession outside the continental United States under a name of State
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.

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 $11,000 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

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 15 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 is optional, however furnishing the information is required in order to obtain and/or retain
benefits (33 U.S.C. 930(b)). 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, 200 Constitution Avenue, N.W., Room C-4319, Washington, D.C. 20210,
and reference the OMB Control Number. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE