Application for Self-Insurance instructions

• Legal Form Number: LS-271
• Issuer: Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation
• Section: U.S. Department of Labor

Application for Self- Insurance U.S. Department of Labor

Office of Workers' Compensation Programs

https://www.dol.gov/agencies/owcp/dlhwc OMB No. 1240-0014

Expires: 11/30/2026

The applicant hereby requests that the Office of Workers' Compensation Programs grant permission for the Applicant to become a self- insured employer in

accordance with Section 32(a)(2) of the Longshore and Harbor Workers' Compensation Act (33 USC 932 (a)(2)) in regard to the employer's obligations

under the Compensation Act checked in item 1. No authorization for self-insurance will be approved unless a completed application form has been

received. [33 USC 932 (a)] [20 CFR 703.302]

The declarations made in this application are for the purpose of enabling the Office of Workers' Compensation Programs to make a finding of facts as to

whether the Applicant possesses sufficient ability to render certain the payment of compensation, the furnishing of medical services and supplies to injured

employees, and the payment of compensation for death in accordance with the provisions of the Act checked in item 1.

The Applicant agrees to make and maintain a deposit of an indemnity bond with the Office OR a deposit of securities with a Federal Reserve Bank (option

to be indicated in Item 6) which shall be an amount determined by the Office and subject to the order of the Office. The Applicant further agrees to abide by

all the rules and regulations administered by the Office pertaining to the Longshore and Harbor Workers' Compensation Act (33 USC 901) or any of the

extensions of the Act checked in item 1.

INSTRUCTIONS: All items are to be completed. If the answer to any item requires more space than provided, please attach a separate sheet and identify

the item you are answering. Information contained herein shall not be open to public inspection.

The Application must be accompanied by: (1) Copies of certified financial statements for the last three years. (2) Copy of the excess loss coverage contract

showing amount of net retention for any one accident and amount of maximum limit, (3) Loss information under the Act for the last five years, showing the

amount of paid and reserved losses. This should be in the form of a letter from the insurance carrier(s), showing the loss information for each year, and (4)

Statement showing amount of annual payroll under the Act by insurance classification.

The application should be mailed to: U.S. Department of Labor, Office of Workers' Compensation Programs, DLHWC Room S-3229, Washington, D.C. 20210.

1. Check only one of the Acts. If you wish to be self-insured under more than once Act, file a separate application for each.

A. [ Longshore and Harbor Workers' Compensation Act (33 USC 901) C. [ Defense Base Act (42 USC 1651)

B. [ Nonappropriated Fund Instrumentalities Act (5 USC 8171) D. [ Outer Continental Shelf Lands Act (43 USC 1331)

2. Name and Address (principal office) of Applicant EIN:

3. NATURE OF BUSINESS - Describe briefly the general character of the operations performed and work done. If more than one class of work is

conducted, indicate division in payroll of each. Description should relate only to operations performed and work done under the Act checked in item 1. Omit

operations performed and work done under the State Compensation Act.

4. Information appearing in the columns below should relate to employees governed by the act checked in item 1 and for which self-insurance authorization

is requested. Omit employees governed by the State Workers' Compensation Act. If you cannot so separate your employees between the act checked in

item 1 and the State Act, give information relating to all employees and indicate that the data covers all your employees.

Work Places and Locations Estimated Number of Employees

a b

5. If you are now authorized as a self- insurer under any state workers' compensation program, give amounts of

indemnity bonds and securities, and the states in which deposited.

a. State b. Amount of Indemnity Bond c. Amount of Securities

6. If this application is granted,

which do you elect to deposit

under this act?

[ Indemnity Bond

[ Securities

[ Letter of Credit

Form LS-271

Rev. Nov 2023

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