LHWCA LONGSHOREMAN INJURY CLAIM

Longshore and Harbor Workers' Compensation Act

PART A: CLAIM FOR COMPENSATION

Filed with U.S. Department of Labor, Office of Workers' Compensation Programs (OWCP)

UNITED STATES DEPARTMENT OF LABOR
Office of Workers' Compensation Programs (OWCP)
Division of Longshore and Harbor Workers' Compensation

FORM LS-203: EMPLOYEE'S CLAIM FOR COMPENSATION

(This section mirrors the official LS-203 form requirements)

SECTION 1: EMPLOYEE INFORMATION

SECTION 2: EMPLOYER INFORMATION

SECTION 3: INJURY/ILLNESS INFORMATION

Location Where Injury Occurred:

Describe How the Injury/Illness Occurred:

[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

Part(s) of Body Injured:

☐ Head/Face
☐ Neck
☐ Shoulder (☐ Left ☐ Right ☐ Both)
☐ Arm (☐ Left ☐ Right ☐ Both)
☐ Elbow (☐ Left ☐ Right ☐ Both)
☐ Wrist/Hand (☐ Left ☐ Right ☐ Both)
☐ Fingers (☐ Left ☐ Right ☐ Both)
☐ Back (☐ Upper ☐ Lower ☐ Both)
☐ Chest
☐ Hip (☐ Left ☐ Right ☐ Both)
☐ Leg (☐ Left ☐ Right ☐ Both)
☐ Knee (☐ Left ☐ Right ☐ Both)
☐ Ankle/Foot (☐ Left ☐ Right ☐ Both)
☐ Toes (☐ Left ☐ Right ☐ Both)
☐ Internal Organs
☐ Occupational Disease: [________________________________]
☐ Other: [________________________________]

Nature of Injury:

☐ Fracture
☐ Sprain/Strain
☐ Laceration
☐ Contusion/Bruise
☐ Amputation
☐ Burn
☐ Crush Injury
☐ Hearing Loss
☐ Respiratory Condition
☐ Repetitive Motion Injury
☐ Other: [________________________________]

SECTION 4: MEDICAL TREATMENT

Current Treating Physician:

SECTION 5: DISABILITY STATUS

Have you lost time from work due to this injury?
☐ Yes ☐ No

If yes:

Type of Disability:

☐ Temporary Total Disability (TTD) - Unable to work at all
☐ Temporary Partial Disability (TPD) - Working but earning less
☐ Permanent Total Disability (PTD) - Permanently unable to work
☐ Permanent Partial Disability (PPD) - Permanent impairment but can work

SECTION 6: LHWCA COVERAGE ELIGIBILITY

STATUS TEST - Were you engaged in maritime employment at the time of injury?

☐ Longshoreman
☐ Ship repairman
☐ Shipbuilder
☐ Ship breaker
☐ Harbor worker
☐ Container handler
☐ Stevedore
☐ Marine terminal operator
☐ Checker
☐ Freight handler
☐ Other maritime employment: [________________________________]

SITUS TEST - Did the injury occur at a covered location?

☐ On navigable waters of the United States
☐ On a pier
☐ On a wharf
☐ In a dry dock
☐ At a marine terminal
☐ In a building way
☐ On a marine railway
☐ In an area customarily used for loading, unloading, repairing, or building a vessel

SECTION 7: WITNESSES

SECTION 8: OTHER CLAIMS/BENEFITS

Are you receiving or have you applied for any of the following?

☐ State Workers' Compensation: [________________________________]
☐ Social Security Disability: [________________________________]
☐ VA Benefits: [________________________________]
☐ Private Disability Insurance: [________________________________]
☐ Other: [________________________________]

Have you filed a third-party lawsuit related to this injury?
☐ Yes ☐ No

If yes, against whom? [________________________________]
Case Number: [________________]
Court: [________________________________]

SECTION 9: BENEFITS CLAIMED

I hereby claim the following benefits under the LHWCA:

☐ Medical Benefits - Payment of all reasonable and necessary medical treatment (33 U.S.C. § 907)

☐ Temporary Total Disability (TTD) - 66 2/3% of average weekly wage during total disability (33 U.S.C. § 908(b))

☐ Temporary Partial Disability (TPD) - 66 2/3% of difference between pre-injury and post-injury wages (33 U.S.C. § 908(e))

☐ Permanent Total Disability (PTD) - 66 2/3% of average weekly wage for life (33 U.S.C. § 908(a))

☐ Permanent Partial Disability (PPD) - Scheduled benefits for specific body parts or percentage of impairment (33 U.S.C. § 908(c))

☐ Vocational Rehabilitation - If unable to return to previous employment (33 U.S.C. § 908(g))

☐ Death Benefits - (If filing on behalf of deceased worker) (33 U.S.C. § 909)

SECTION 10: AVERAGE WEEKLY WAGE CALCULATION

Method of Calculation (33 U.S.C. § 910):

☐ Standard Method: Wages earned in the 52 weeks before injury ÷ 52

☐ Alternative Method: If employed less than 52 weeks

Calculated Average Weekly Wage: $[________________]

Compensation Rate (66 2/3% of AWW): $[________________]

(Subject to maximum and minimum rates established by DOL)

SECTION 11: SIGNATURE AND CERTIFICATION

I certify that the above statements are true and complete to the best of my knowledge and belief. I understand that any person who knowingly makes a false statement or misrepresentation for the purpose of obtaining benefits under the LHWCA is subject to criminal prosecution under 18 U.S.C. § 1920 and civil penalties under 33 U.S.C. § 931.

______________________________________
Claimant's Signature

Date: [__/__/____]

PART B: THIRD-PARTY COMPLAINT AGAINST VESSEL OWNER

33 U.S.C. § 905(b)

IN THE UNITED STATES DISTRICT COURT

FOR THE [________________________________] DISTRICT OF [________________________________]

[________________________________],
Plaintiff,

v. Civil Action No. [________________]
IN ADMIRALTY

[________________________________],
as owner and/or operator of the
M/V [________________________________],
Defendant.

COMPLAINT FOR DAMAGES UNDER 33 U.S.C. § 905(b)

(Third-Party Vessel Negligence)

Plaintiff, [________________________________] ("Plaintiff"), by and through undersigned counsel, brings this action for damages against Defendant and alleges as follows:

I. NATURE OF THE ACTION

1. This is an action by a longshoreman against a vessel owner for negligence pursuant to Section 5(b) of the Longshore and Harbor Workers' Compensation Act, 33 U.S.C. § 905(b).

2. Plaintiff invokes the admiralty and maritime jurisdiction of this Court.

II. PARTIES

3. Plaintiff [________________________________] was at all relevant times a longshoreman/harbor worker employed by [________________________________] (the "Stevedore").

4. Defendant [________________________________] was at all relevant times the owner, operator, and/or bareboat charterer of the vessel M/V [________________________________] (the "Vessel").

III. JURISDICTION AND VENUE

5. This Court has original jurisdiction pursuant to 28 U.S.C. § 1333 (admiralty) and 33 U.S.C. § 905(b).

6. Venue is proper in this District pursuant to 28 U.S.C. § 1391(b).

IV. FACTS

7. On [__/__/____], Plaintiff was working as a [________________________________] aboard the Vessel, which was docked at [________________________________].

8. Plaintiff's work involved [☐ loading] [☐ unloading] [☐ repairing] [☐ other: ________________] the Vessel.

9. While performing this work, Plaintiff was injured when:

[________________________________]
[________________________________]
[________________________________]
[________________________________]

10. The injury was caused by a dangerous condition on the Vessel, specifically:

[________________________________]
[________________________________]

V. VESSEL OWNER'S DUTY

11. Under Scindia Steam Navigation Co. v. De Los Santos, 451 U.S. 156 (1981), and its progeny, Defendant as vessel owner owed Plaintiff three duties:

A. The Turnover Duty

12. Defendant had a duty to exercise ordinary care to turn over the ship and its equipment in a condition that would allow the stevedore to carry on cargo operations with reasonable safety.

13. Defendant breached this duty by:

☐ a. Failing to warn of latent or hidden dangers known to the vessel;

☐ b. Turning over unsafe equipment;

☐ c. Failing to disclose hazardous conditions;

☐ d. [________________________________]

B. The Active Control Duty

14. If Defendant actively involved itself in cargo operations, it had a duty to exercise reasonable care.

15. Defendant breached this duty by:

☐ a. Negligently participating in cargo operations;

☐ b. Creating a dangerous condition during operations;

☐ c. [________________________________]

C. The Duty to Intervene

16. Defendant had a duty to intervene if it knew that the stevedore was using defective equipment or creating a dangerous condition that posed an unreasonable risk of harm and the stevedore failed to correct it.

17. Defendant breached this duty by:

☐ a. Failing to intervene when aware of dangerous conditions;

☐ b. Failing to stop operations when hazards were observed;

☐ c. [________________________________]

VI. NEGLIGENCE

18. Defendant was negligent in one or more of the following respects:

☐ a. Failing to provide a safe place to work;

☐ b. Failing to maintain the vessel in a safe condition;

☐ c. Failing to warn of known hazards;

☐ d. Failing to provide safe and adequate equipment;

☐ e. Failing to remedy known dangerous conditions;

☐ f. Creating dangerous conditions;

☐ g. Failing to intervene when aware of hazards;

☐ h. [________________________________]

19. Defendant's negligence was a proximate cause of Plaintiff's injuries.

VII. DAMAGES

20. As a direct and proximate result of Defendant's negligence, Plaintiff has suffered:

a. Physical injuries: [________________________________]

b. Past medical expenses: $[________________]

c. Future medical expenses: $[________________]

d. Past lost wages: $[________________]

e. Future lost wages/loss of earning capacity: $[________________]

f. Pain and suffering, past and future

g. Mental anguish and emotional distress

h. Loss of enjoyment of life

i. Permanent disability/disfigurement

VIII. CREDIT FOR LHWCA BENEFITS

21. Plaintiff has received [or will receive] workers' compensation benefits under the LHWCA from Stevedore's insurance carrier.

22. Pursuant to 33 U.S.C. § 933(f), Defendant is entitled to a credit for compensation paid by the Stevedore's insurer.

IX. PRAYER FOR RELIEF

WHEREFORE, Plaintiff prays that this Court:

A. Enter judgment in favor of Plaintiff;

B. Award Plaintiff compensatory damages in excess of any LHWCA compensation received;

C. Award Plaintiff pre-judgment and post-judgment interest;

D. Award Plaintiff costs of suit; and

E. Grant such other relief as is just and proper.

Respectfully submitted,

[________________________________]
Attorney for Plaintiff
Bar No.: [________________]
[________________________________]
Telephone: [________________________________]
Email: [________________________________]

Date: [__/__/____]

IMPORTANT DEADLINES

FILING INFORMATION

File LHWCA claims with:

U.S. Department of Labor
Office of Workers' Compensation Programs
Division of Longshore and Harbor Workers' Compensation

District Offices:

• Boston: [Address]
• New York: [Address]
• Norfolk: [Address]
• Jacksonville: [Address]
• New Orleans: [Address]
• Houston: [Address]
• Long Beach: [Address]
• San Francisco: [Address]
• Seattle: [Address]
• Honolulu: [Address]

Online: https://www.dol.gov/agencies/owcp/dlhwc

SOURCES AND REFERENCES

• LHWCA (33 U.S.C. §§ 901-950): https://www.law.cornell.edu/uscode/text/33/chapter-18
• DOL LHWCA Program: https://www.dol.gov/agencies/owcp/dlhwc
• 33 U.S.C. § 905(b): https://www.law.cornell.edu/uscode/text/33/905
• Scindia Steam Navigation Co. v. De Los Santos, 451 U.S. 156 (1981)
• 20 C.F.R. Part 702: https://www.law.cornell.edu/cfr/text/20/part-702