This report is to be filed in duplicate with the District Director in unless the physician is on a list of physicians currently not
the appropriate district office of the Office of Workers’ authorized by the Department of Labor to render medical
Compensation Programs and is required by 33 U.S.C. 930(a). care under the Act. Compensation payments become due and
File form within 10 days from the date of injury or death or are payable on the 14th day after the employer first has knowledge
from the date the employer first has knowledge of an injury or of the injury or death. Penalties may be charged for failure to
death. Under the law all medical treatment and compensation comply with provisions of the law. The information will be used to
must be furnished by the employer or its insurance company. determine entitlement to benefits. Persons are not required to
Treatment must be by a physician chosen by the employee. 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, O 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 O 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. Defense Base Act covers any employment (1) at military, Name or number of pier, dry dock, marine railway, etc.
air, and naval bases acquired by the United States from foreign Name of the terminal or shipyard
countries; (2) on lands occupied or used by the United States Nearest street address – City and State
for military or naval purposes outside the continental limits of
the United States; (3) upon any public work in any Territory or O If on a military or Defense Base,
possession outside the continental United States under a
contract of a contractor with the United States; (4) under a Give exact place on base where injury happened
contract entered into with the United States where such Name of base
contract is to be performed outside the continental United Location of base – town or country
States and at places not within the areas described in (1), (2),
and (3) above for the purpose of engaging in public work; (5) O If on the Outer Continental Shelf,
under certain contracts approved and financed by the United
States under the Mutual Security Act of 1954, as amended; and Give drilling site and block number
(6) in the service of American employers providing welfare or Area name (e.g. West Delta Area)
similar services for the benefit of the Armed Forces outside the Federal Lease Number, State Lease Number
Continental United States. Distance from and name of nearest land,
name of State
C. Nonappropriated Fund Instrumentalities Act covers
employees of nonappropriated fund instrumentalities of the
Armed forces, e.g., post exchanges, motion picture service,
etc.
D. Outer Continental Shelf Lands Act covers employees of
private employers engaged in operations conducted on the
Outer Continental Shelf for the purpose of exploring for,
developing, removing, or transporting by pipeline the natural
resources of submerged lands.
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 $10,000 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
We estimate that it will take an average of 15 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, 200 Constitution Avenue, N.W.,
Room C-4315, Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
