(a) Any information required by the regulations in this part to be submitted to OWCP must be submitted on forms the Director authorizes from time to time for such purpose. Persons submitting forms may not modify the forms or use substitute forms without OWCP’s approval. These forms must be submitted, sent, or filed in the manner prescribed by OWCP.

medical exam

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Form No.Title
(1) LS-271Application for Self-Insurance.
(2) LS-274Report of Injury Experience.
(3) LS-275 SISelf-Insurer’s Agreement and Undertaking.
(4) LS-275 ICInsurance Carrier‘s Agreement and Undertaking.
(5) LS-276Application for Security Deposit Determination.
(6) LS-405Indemnity Bond.
(7) LS-570Card Report of Insurance.

(b) Copies of the forms listed in this section are available for public inspection at the Office of Workers’ Compensation Programs, U.S. Department of Labor, Washington, DC 20210. They may also be obtained from OWCP district offices and on the Internet at http://www.dol.gov/owcp/dlhwc.

[70 FR 43233, July 26, 2005, as amended at 77 FR 37286, June 21, 2012; 80 FR 12932, Mar. 12, 2015]

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