Defense Base Act Forms

grossman-icon
All The Forms in One Place

Download commonly Used Forms in DBA Claims

For questions on how to complete these forms, contact us for free tips from one of our lawyers.

grossman-icon

The U.S. Department of Labor (DOL) uses a variety of Defense Base Act (DBA) forms to process claims and ensure their own compliance with federal regulations. Accurately completing and timely filing your DBA forms is crucial to the success of your claim.

LS-18: Pre-Hearing Statement

The Form LS-18 is a formal request for a hearing before the Office of Administrative Law Judges (OALJ), which serves as the administrative trial court for the DOL. Either the claimant or insurance carrier will file the form.

You can only submit Form LS-18 after the issuance of a Memorandum of Informal Conference, which indicates that your claim could not be resolved informally. After the OALJ receives your LS-18, they will send a Notice of Hearing and Pre-hearing Order. These documents are official notice that your claim was received and scheduled on the trial calendar.  

LS-200: Report of Earnings

This form is a request to obtain actual documentation of your earnings. If you receive disability compensation benefits, your employer, insurance carrier, or the Director of the Office of Worker’s Compensation Programs (OWCP) may require you to complete a Form LS-200 to confirm your earnings and continued eligibility to receive benefits.

Some employees receiving benefits may have to file this form semiannually. If you do not complete and submit the form in a timely manner, you may forfeit your compensation payments. 

LS-201: Notice of Employee’s Injury or Death

The Form LS-201 notifies the employer of the employee’s injury or death. This is important to file so that the injured employee or a deceased employee’s family can receive compensation for loss of income as quickly as possible.

Either the injured employee or survivors of the employee must file the form. Failure to file Form LS-201 could result in loss of benefits. Generally, the person submitting the form must do so within 30 days of the date of injury or death.

LS-202: Employer’s First Report of Injury or Occupational Illness 

The LS-202 is the employer’s initial report of an injury or occupational illness sustained by an employee. When an employee suffers an injury, the employer must file the Form LS-202 with the OWCP.

The form needs to be filed within 10 days of any injury which causes loss of one or more shifts of work, or within 10 days from the date that the employer has knowledge of a disease or infection that results from an injury.

Employers who do not file properly or timely with the OWCP can face harsh penalties. An employer should not wait to substantiate all information related to the injury or death before submitting the form.  

LS-203: Employee’s Claim for Compensation 

The Form LS-203 is a formal request for payment of medical and/or compensation benefits after a work-related injury. The injured employee is responsible for filing the form with the OWCP. There are specific and strict filing deadlines for this form, so it is beneficial to hire an attorney to help you file on time.  

LS-204: Attending Physician’s Supplementary Report 

The attending physician of an injured employee will use a Form LS-204 to track progress and make a final report upon the employee’s discharge. This form is typically submitted every 30 days to the OWCP.  

OWCP-5A: Work Capacity (Psychiatric/Psychological Conditions) 

An injured employee’s attending physician may be asked to complete this form to provide more information and clarity regarding an employee’s psychiatric or psychological condition. The DOL often asks for this form if they lack information to substantiate a disability benefits claim. Your employer could modify your work assignments based on the doctor’s assessment. 

OWCP-5b: Work Capacity (Cardiovascular/Pulmonary) 

The OWCP-5b is an evaluation form documenting the injured employee’s ability to work with a cardiovascular or pulmonary condition. The DOL often requests this form if they lack information to substantiate a claim for disability benefits. Your employer could modify your work duties based on the physician’s evaluation. 

OWCP-5c: Work Capacity (Musculoskeletal Conditions) 

The injured employee’s physician must complete this form if the employee has a musculoskeletal condition. The doctor must provide an evaluation of the employee’s work abilities and limits based upon their condition.

The DOL often asks for this form if they lack information to substantiate a claim for disability benefits. Your employer could modify your work duties based on the physician’s evaluation found in this form.  

Contact a Defense Base Act Lawyer

At Grossman Attorneys at Law, we know the DBA forms inside and out. We will walk you through the necessary forms you need to submit for your claim. And we are always here to answer any questions you may have. Don’t let incomplete or past due paperwork be the reason you lose out on benefits. Contact us today for assistance or questions.

WE ARE NOT AFRAID TO TAKE YOUR CASE TO TRIAL

Wherever You Need Us to Be.

Please fill out this form and one of our lawyers will contact you.

grossman-icon