Application for Security Deposit Determination. State Guarantee Fund Longshore Security Factor Chart

Application for Security Deposit Determination                                     U.S. Department of Labor
                                                                                   Office of Workers' Compensation Programs
       Print            Reset                                                       OMB Form No. 1240-0005 Exp Date: 11/30/2026

An insurance carrier authorized to write insurance for the payment of compensation under the Longshore and Harbor Workers' Compensation Act, 33
USC 901-950, or any of its extensions must fully secure its payment obligations under these statutes by depositing security in an amount determined by
the Office of Workers' Compensation Programs. On an annual basis, each authorized carrier (or a carrier seeking authorization) must complete this
application. The information in this application will help the Office determine the security amount necessary to fully secure the carrier's payment of
compensation, medical services and supplies, and any other obligations it has under these statutes.

No authorization for insurance carriers will be approved unless a complete application form has been received. (33 USC 932; 20 CFR
703.203). Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.


INSTRUCTIONS: Please complete all items. If your answer requires more space than provided, please attach a separate sheet(s) for each
and identify the item you are answering. Information contained in this application will not be open to public inspection.

You must also complete Form LS-274, Report of Injury Experience, and submit it as part of this application.

Please submit the completed application and any attachments to: US Department of Labor, Office of Workers' Compensation Programs, Division of
Longshore and Harbor Workers' Compensation, Room S-3229, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

1.              Application Period: January 1,                 to December 31,

2. Insurance Carrier's Name and Address (Principal Office)




                                    Sequence #:                                         EIN:

3.         Check all acts that you are authorized to write insurance under:
      A.         Longshore and Harbor Workers' Compensation Act (LHWCA)                 C.      Defense Base Act (DBA)
                 (33 USC 901)                                                                   (42 USC 1651)
      B.         Nonappropriated Fund Instrumentalities Act (NAFI)                      D.      Outer Continental Shelf Lands Act (OCSLA)
                 (5 USC 8171)                                                                   (43 USC 1331)

4.         Telephone Number:                                                       5.          Facsimile Number:

6. Are you applying for an exemption from the security deposit requirements (see 20 C.F.R. 703.203(a)(1))?                                  No
                                                                                                                          Yes

If you checked yes, you must attach documentation establishing your current rating and your rating for the immediately preceding year from each
insurance rating service designated by OWCP and posted on the Internet at http://www.dol.gov/owcp/dlhwc/index.htm.

If you checked no, proceed to number 7.

7. Columns a and b: Report your outstanding payment obligations under the LHWCA, and /or its extensions, for each state in which the liabilities
arose. (Please base your report on your completed form LS-274, Report of Injury Experience.) Column c: List the percentage of the liabilities reported
in columns a and b based on the current status of each state's guaranty fund's protection for Longshore benefits: The Office's determination of each
state's coverage was transmitted to you with this application form. It is also available on the internet at http://www.dol.gov/owcp/dlhwc/index.htm. If you
use a percentage different from the Office's determination for any particular state, you should submit documentation supporting your conclusion.
Column d: Enter deposit amount you believe will fully secure your obligations in each state. NOTE: A separate LS-274 must be submitted for each
state along with an attachment stating the information submitted is ''certified as true and accurate'' and must bear the notarized signature of a corporate
officer.

     a. STATE                               b. TOTAL                               c. PERCENT                      d. ESTIMATED
                                               OBLIGATIONS                              UNSECURED                     DEPOSIT




8.         Total estimated security deposit amount: $


                                                                                                                                               Form LS-276
                                                                                                                                               April 2009
                                                                              (2)

                                                                                                                                       OMB No. 1240-0005




I certify that I am an official of the applicant, duly authorized to file this application. I have carefully examined the statements made on the application,
including the information contained in any additional sheets attached, and certify that the information supplied is true. I agree to inform the Office
immediately of any changes that render the information I have supplied here incomplete, inaccurate or misleading.




                           Signature                                                                               Date

Official's Name and Title (Printed):

If insurance carrier is a corporation, affix Corporate Seal.




                                                               DO NOT WRITE IN THE SPACE BELOW

8.          Date Application Received




                                                                PUBLIC BURDEN STATEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a
valid OMB control number. Public reporting burden for this collection of information is estimated to average 1 hour per response, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Use of this form is optional, however furnishing the information is required in order to obtain and/or retain benefits (20CFR 703.203). Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S.
Department of Labor, 200 Constitution Avenue, N.W., Room S-3229, Washington, D.C. 20210, and reference the OMB Control Number.


                                                                                                                                                 Form LS-276
                                                                                                                                                 April 2009