Notice of Final Payment or Suspension of Compensation Payments

• Legal Form Number: LS-208
• Issuer: Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation
• Section: U.S. Department of Labor

1

12. Type of Notice

Notice of Payments

(Longshore and Harbor Workers' Compensation Act,

as extended)

U.S. Department of Labor

Office of Workers' Compensation Programs

OMB No. 1240-0041

Expires: 08/31/2027

1. Date of Accident/Illness: 3. OWCP No.2. Carrier's No.

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

7. Date employee first lost time (Month, day, year) 8. Average Weekly Wage $ Compensation Rate $

Subject to MIN/MAX rates

9. Payment Begin Date (Month, day, year)

If different than date of first lost time, state reason:

10. Employer continuing to pay the injured person's salary? Yes No

If so, are salary continuation payments made in lieu of compensation

payments.

Yes No

11. Date of first check ever issued on this claim

(Month, day, year)

Initial (MUST complete 6-11)

Interim

Final

13. State reason for interim or final payment notice:

14. Date last payment made:

15. ENTER ALL PAYMENTS MADE ON ACCOUNT OF DISABILITY

TOTAL PAID:

Attach continuation sheet to show additional periods, rates and amounts:

ENTER OTHER PAYMENTS

16.

Form LS-208

Rev. Aug. 2021

2. Medical

TYPE OF DISABILITY

a

FROM

(Mo., day, yr.)

b

THROUGH

(Mo., day, yr.)

c

AMOUNT PAID

PER WEEK

d

NUMBER OF

WEEKS PAID

e

TOTAL

f

Disfigurement

Permanent partial

Percent

Part of body

a. Section 8(i) Settlement: 1. Compensation

b. Compensation for late payment per Sec. 14(e) or (f)

e. Beneficiary payments:

17. Employer Name:

(schedule loss)

c. Interest

d. Attorney Fee

f. Funeral Expenses

g. Sec. 44(c)(1) payment to the Special Fund

h. Commutation

EMPLOYEE-

PLEASE

READ

CAREFULLY

18. Name of insurance carrier or self-insured employer and administrator:

17a. Employer Address: 18a. Address and phone number of person whose name is shown in Box 18:

19. Signature of person authorized to sign for employer or carrier 21. Date of notice:

20. Print name of authorized person:

AS VERIFIED BY THE SIGNATURE BELOW, THIS FORM WAS MAILED TO THE CLAIMANT AND CLAIMANT'S REPRESENTATIVE

6. Compensation Disability type:

Select type:

Select type:

Information collected on this form will be used to determine whether compensation payments were timely and properly

made under the Longshore and Harbor Workers’ Compensation Act, 33 U.S.C. 901 et seq., and its extensions, the

Defense Base Act, 42 U.S.C. 1651 et seq., the Outer Continental Shelf Lands Act, 43 U.S.C. 1333(b), the

Nonappropriated Funds Instrumentalities Act, 5 U.S.C. 8171, et seq., and the District of Columbia Workers’ Compensation

Act of 1928, D.C. Code 1928, 36-501 et seq. 33 U.S.C. 914. Use of this form is mandatory. 33 U.S.C. 914(c), (g). In Item

12, check the box for the type of payment you are reporting. Complete the remainder of the form as appropriate.

Any claim for compensation, to be valid, must be filed IN WRITING with the District Director, OWCP, WITHIN ONE YEAR after

the date of injury or date of last payment of compensation. If you have any impairment of the body, serious disfigurement,

or other disability from the injury which may handicap you in securing or maintaining employment you should submit a claim

to the U. S. Department of Labor. Please be sure to include the OWCP Case Number.

5. Claimant's Address:

Is this an Amended

filing? Yes No

If yes, list Box(es) Amended (i.e. Box 8, 15)

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