AR 215-1 - Soldier Support Institute - U.S. Army

h. Any claimant or claimant’s representative who knowingly and willfully makes a false statement to obtain
workers’ compensation benefits is guilty of a felony that may result in a fine, imprisonment, or both.
i. Any person who knowingly and willfully makes a false statement to reduce, deny, or terminate benefits to an
injured employee may be fined, imprisoned, or both.
j. All NAFIs/entities will post a copy of Department of Labor Form LS–242(NF) (Notice of Workers’ Compensation
Benefits) in a place that is conspicuous and accessible to all NAF employees. This form states that the employing
NAFI/entity holds required workers’ compensation coverage. Table 19–4 is a listing of the forms.
Table 19–4
Workers’ Compensation claim forms
Form Number: LS–1 (Request for Examination or Treatment)
Preparer: Part A, Program manager with coordination of the CPAC–NAF (original and 2 copies). This form must be signed by the program
manager. Part B, Doctor. This form must give the name of the physician or medical facility.
Disposition: Give to employee. Authorization is given only once. If more than one authorization is given to the employee, the NAFI/entity will
be liable for the expense incurred. Send original to the district office and a copy to the claims service contractor.
Remarks: Part A, Authorizes doctors to treat the employee and the claims services contractor to pay the bill.
Form Number: LS–202 (Employer’s First Report of Injury or Occupational Illness)
Preparer: Employer, after injury or death whether by the employer’s written notice or from other sources (original and 4 copies)
Disposition: File 2 copies with the district office, send 1 copy to the claims service contractor, 1 copy to the RIMP, and retain 1 copy
Remarks: The LS–202 must be fully completed by the program manager and filed within 10 days
Form Number: LS–204 (Attending Physician Supplementary Report)
Preparer: Doctor: These are sent after the first report (Part B, LS–1)
Disposition: Sent to the district office and the claims service contractor
Remarks: Updates treatment record. A physician’s report will be acceptable instead of the LS–204
Form Number: LS–206 (Payment of Compensation Without Award)
Preparer: The claims service contractor, when compensation is begun and eligibility is not questioned
Disposition: Sent to the district office and to injured employee with first check by the claims service contractor
Remarks: Starts disability payments
Form Number: LS–207 (Notice to District Director Right to Compensation is Controverted)
Preparer: The claims service contractor, when employer advises employee was not injured on the job, is not eligible for compensation, or a
question of compensability arises
Disposition: Sent to the district office by the claims service contractor only
Remarks: Benefits will not be paid until a determination of compensability is made.
Form Number: LS–208 (Compensation Payment Stopped or Suspended)
Preparer: The claims service contractor, when employee has returned to work or payments have been completed
Disposition: Sent to the district office and employee by the claims service contractor
Remarks: Stops disability payments
Form Number: LS–210 (Supplementary Report of Accident or Occupational Illness)
Preparer: Employer, every pay period when employee loses time because of an on-the-job incident
Disposition: Sent to the claims service contractor
Remarks: Documents lost time due to on-the-job injury
Form Number: LS–222 (Carrier’s or Self-Insurer’s Report on Rehabilitation to Deputy Commissioner)
Preparer: The claims service contractor, after an employee has been continuously disabled for 60 days or more
Disposition: Sent to District Director’s office by claims service contractor
Remarks: Requests rehabilitation services by the Department of Labor
Form Number: LS–242 (NF) (Notice of Workers’ Compensation Benefits)
Preparer: NAFI/entity personnel office
Disposition: ACIF sends to NAFI/entity
Remarks: A printed poster, which should be clearly displayed in the workplace. It advises employees that compensation for on-the-job
injuries is available through the employer under LHWCA
19–83. Benefits
a. Medical care. This includes medical treatment services, medicines, and supplies, subject to provisions of the
Longshore and Harbor Workers’ Compensation Act (LHWCA).
160 AR 215–1 • 31 July 2007