Commutation Application

U.S. Department of Labor
Commutation Application                                                         Office of Workers' Compensation Programs



You must use this form to request approval of commutation of compensation under 33 U.S.C. 909(g)                  OMB No.: 1240-0058
or 42 U.S.C. 1652. You must attach documentation supporting your request if you have not already                  Expires: 04/30/2029
submitted it.
Submit form to the OWCP/DLHWC Central Mail Receipt site                          Or upload directly to the case file using the
at the following address:                                                        Secure Electronic Access Portal (SEAPortal)
U.S. Department of Labor, Office of Workers' Compensation Programs
DLHWC                                                                            Access the SEAPortal directly at:
400 West Bay Street, Suite 63A, Box 28                                           https://seaportal.dol.gov/portal/
Jacksonville, FL 32202
1. Date of Accident/Illness:                       2. Carrier's No.                        3. OWCP No.



4. Name of Injured Worker and Claimant if other than injured worker


5. This Commutation is for: (select one)         Permanent Partial Disability        Permanent Total Disability         Death Benefits

6. Country of Residence

7. Average Weekly Wage                                                 8. Compensation Rate

9. Describe the nature of the incident (i.e, gunshot, IED) with documentation




10. Identify official confirmation of the nature of the incident




11. Has a compensation Order issued?                                   Yes            No
12. Have stipulations been submitted confirming details of the incident?
                                                                    Yes               No

13. If you are an employer or insurance carrier, have you attached an interim LS-208 form documenting all payments made?
                                                                    Yes            No

14. On a death case, the following documentation must be attached or previously submitted: death certificate, marriage certificate, birth
certificate for all dependent children, evidence of other dependents

15. Name and date of birth, initial compensation rate of each beneficiary

Name                                             Date of Birth                       Initial Compensation Rate




                               I certify that all of the information above and in the attachments is accurate.
               I also certify that I have served the form and attachments on all other parties and their representatives.
16. Print Name                                         17. Signature                                   18. Date (Month, Day, Year)


                                                            Print            Reset                                               Form LS-6
                                           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 burden for this collection of
   information is estimated to average 10 minutes 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 required to request approval of commutation of
 compensation by the Office of Workers’ Compensation Longshore Program under 33 U.S.C. 909(g) or 42
    U.S.C. 1652. 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, NW, Room S-3524, Washington, D.C. 20210 and reference the OMB Control Number.
                         Note: Please do not return the completed LS-6 to this address.




                          DO NOT SEND COMPLETED FORMS TO THIS OFFICE.


                                         PRIVACY ACT STATEMENT

The following information is provided in accordance with the Privacy Act of 1974, as amended, 5 USC 552a.
(1) This collection of information is authorized under the Longshore and Harbor Workers’ Compensation Act
(LHWCA) and its extensions. (2) The information will be used to determine eligibility for commutation of
benefits. (3) Use of this form is required to request approval of commutation of compensation by the Office
of Workers’ Compensation Longshore Program. (4) Disclosures of this information may be made to: the
claimant and his or her representative(s); the employer, the insurance carrier or other entity that secured the
employer’s compensation liability, and their representative(s); the Department of Labor’s Office of
Administrative Law Judges (OALJ), or other person, board or organization, authorized or required to render
decisions on claims or other matters arising in connection with a claim; Federal, state and local agencies to
determine whether benefits are being and have been paid properly and, where appropriate, to pursue
salary/administrative offset and debt collection actions required or permitted by law; and other individuals,
their representatives, and government agencies enforcing a legal obligation for alimony or child support. (5)
Failure to provide the information on this form may delay consideration of the application or result in denial of
the application. (6) This information is included in two Systems of Records, DOL/OWCP-3, 4, published at
81 Federal Register 25765, 25859-61 (April 29, 2016), or as updated and republished.




                                                                                                                    Form LS-6
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