Waiver of Service by Registered or Certified Mail for Employers and/or Insurance Carriers

• Legal Form Number: LS-801
• Issuer: Office of Workers' Compensation Programs - Division of Federal Employees', Longshore and Harbor Workers' Compensation
• Section: U.S. Department of Labor

Name of Injured/Deceased

Employee: OWCP No:

WAIVER OF SERVICE BY REGISTERED OR CERTIFIED MAIL

FOR EMPLOYERS AND/OR INSURANCE CARRIERS

Longshore and Harbor Workers' Compensation Act,

As Extended (see instructions on reverse)

U.S. Department of Labor

Office of Workers' Compensation Programs

www.dol.gov/owcp/dlhwc/index.htm

2. OMB No: 1240-0053

Exp. Date: 06/30/2025

NEW Waiver

REVOKE prior Waiver

CHANGE information on prior Waiver

Party or Representative Agreeing to Service of Compensation Order(s) by email (check one):

Employer

Employer's Representative

Insurance Carrier

Insurance Carrier's Representative

I, , acting on behalf of , waive the

company's statutory and/or regulatory right to be served with the compensation order(s) in this case by registered or certified mail. I

instead request and consent for the company to be served with the compensation order(s) in this case by email. I agree that service of

the compensation order(s) by email satisfies all service requirements imposed by 33 U.S.C. § 919(e) and 20 C.F.R. § 702.349.

I affirm that I have the authority to execute this waiver on behalf of . I also affirm that the

information provided below is correct and accurate. If the District Director is unable to accomplish service of the compensation order(s)

by email (i.e. if the email bounces back as undeliverable), I understand and agree that the compensation order(s) will be served on the

company by registered or certified mail.

Signature: Date:

Name:

Title:

Firm or Business Name (if applicable):

Address: Telephone Number:

EMAIL ADDRESSES: No more than two (2) email addresses can be listed per party.

Name:

Line1:

Line2:

City:

St.: Zip:

Country:

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 5 minutes per response, for locating the

form on the internet, completing the information required and either mailing or uploading the form via secure portal. Use of this form is optional. 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, 200 Constitution Avenue, NW, Room C-4319, Washington, D.C. 20210, and reference the OMB Control Number.

Form LS-801

March 2015

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