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Payment Of Compensation Without Award LS-206 - Official Federal Forms

Payment Of Compensation Without Award Form. This is a national form and can be used in US Dept Of Labor .
 Fillable pdf Last Modified 9/19/2011
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Payment Of Compensation Without Award (Longshore and Harbor Workers' Compensation Act, as extended) U.S. Department of Labor Office of Workers' Compensation Programs 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). 3. Name of injured person (First, middle, last - please print or type) 1. OWCP No. FOR OFFICE USE 2. CARRIER'S No. 4. Address of injured person (Number, street, city, state and ZIP code) United States 5. Date of accident or first illness (Month, day, year) 6. Date disability began (Month, day, year) 7. Name of injured, or dependents of injured, to whom compensation will be paid 8. Average weekly wage $ multiplied by 2/3 compensation rate $ (Mark if maximum rate is being paid) Yes No 9. Compensation will be paid from - Enter month, day, year. 9a. For DBA cases only, is the employer continuing to pay the injured person's salary? Yes No until notice is given that payment has been stopped or suspended I0. Date of first payment (Month, day, year.) 9b. If so, are these salary continuation payments being made in lieu of compensation payments? 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
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