Edit, Download, and Sign the Notice of Employee's Injury Death Compensation Form
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How do I fill this out?
To fill out this form, begin by gathering all necessary personal and employment information. Follow each instruction carefully to ensure accurate completion. Once filled, submit it to the appropriate employer representative.
How to fill out the Notice of Employee's Injury Death Compensation Form?
1
Gather personal and employment information.
2
Carefully fill out each required section.
3
Double-check for accuracy and completeness.
4
Sign the form as necessary.
5
Submit the form to your employer.
Who needs the Notice of Employee's Injury Death Compensation Form?
1
Injured employees who want to report their injury.
2
Survivors of deceased employees needing to claim benefits.
3
Employers needing to document workplace injuries.
4
Insurance agents managing compensation claims.
5
Legal representatives assisting injured workers.
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1
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What are the instructions for submitting this form?
Submit this form electronically through the Secure Electronic Access Portal at https://seaportal.dol.gov/portal/. Alternatively, you can submit by fax to (202) 513-6814. For mail submissions, send the completed form to U.S. Department of Labor, Office of Workers' Compensation Programs, Division of Federal Employees, Longshore and Harbor Workers' Compensation, 400 West Bay Street, Suite 63A, Box 28, Jacksonville, FL 32202. Ensure your OWCP case number is included if avail...
What are the important dates for this form in 2024 and 2025?
This form is valid until November 30, 2026. Ensure to submit claims within 30 days of injury or death occurrence to maintain eligibility for benefits.
What is the purpose of this form?
The purpose of this form is to officially notify employers about an employee's injury or death occurring from occupational activities. It is critical for enabling the employee or their survivors to claim benefits under the Longshore and Harbor Workers' Compensation Act. Properly completed forms ensure that the necessary medical care and compensation support are provided without delay.
Tell me about this form and its components and fields line-by-line.
- 1. Employee's Name: Full name of the injured employee.
- 2. Home Mailing Address: Complete address for correspondence.
- 3. Date of Birth: Employee's birth date for identity verification.
- 4. Social Security Number: Mandatory for claim processing.
- 5. Date of Injury: Date when the injury occurred.
What happens if I fail to submit this form?
Failing to submit this form may result in delays in claims processing and potential forfeiture of benefits.
- Delayed Medical Care: Without timely notification, medical services may be delayed.
- Loss of Compensation: Missing submission deadlines could lead to loss of income support.
- Legal Consequences: Failure to report may result in legal issues for the employee.
How do I know when to use this form?
- 1. Employee Injury Reporting: To file a claim for any injury sustained while working.
- 2. Death Benefit Claims: For survivors seeking compensation after an employee's death.
- 3. Documenting Workplace Incidents: To ensure compliance with legal requirements for workplace safety.
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