20 CFR § 703.2 - Forms.

§ 703.2 Forms.

(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.

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