Commutation Application

• Legal Form Number: LS-6
• Issuer: Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation
• Section: U.S. Department of Labor

11. Has a compensation Order issued?

5. This Commutation is for: (select one)

U.S. Department of Labor

Office of Workers' Compensation Programs

Commutation Application

You must use this form to request approval of commutation of compensation under 33 U.S.C. 909(g)

or 42 U.S.C. 1652. You must attach documentation supporting your request if you have not already

submitted it.

OMB No.: 1240-0058

Expires: 03/31/2026

Or upload directly to the case file using the

Secure Electronic Access Portal (SEAPortal)

Access the SEAPortal directly at:

https://seaportal.dol.gov/portal/

Submit form to the OWCP/DFELHWC Central Mail Receipt site

at the following address:

U.S. Department of Labor, Office of Workers' Compensation Programs

DFELHWC

400 West Bay Street, Suite 63A, Box 28

Jacksonville, FL 32202

4. Name of Injured Worker and Claimant if other than injured worker

3. OWCP No.2. Carrier's No.

1. Date of Accident/Illness:

Permanent Partial Disability Permanent Total Disability Death Benefits

6. Country of Residence

7. Average Weekly Wage 8. Compensation Rate

9. Describe the nature of the incident (i.e, gunshot, IED) with documentation

10. Identify official confirmation of the nature of the incident

Yes No

12. Have stipulations been submitted confirming details of the incident?

Yes No

13. If you are an employer or insurance carrier, have you attached an interim LS-208 form documenting all payments made?

Yes No

14. On a death case, the following documentation must be attached or previously submitted: death certificate, marriage certificate, birth

certificate for all dependent children, evidence of other dependents

15. Name and date of birth, initial compensation rate of each beneficiary

Form LS-6

Name Date of Birth Initial Compensation Rate

I certify that all of the information above and in the attachments is accurate.

I also certify that I have served the form and attachments on all other parties and their representatives.

18. Date (Month, Day, Year)17. Signature16. Print Name

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