Official Legal Form
LHWCA Uniform Stipulations Form
Published by US Dept. of Labor — Forms. Mirrored here in its unmodified, original form for free public access.
Federal
Administrative
Public domain
PDF
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Jun 2026
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FED
Jurisdiction
How to use this form
When & how to file
Quick guide: File this form as instructed by the issuing court or agency. Read the official instructions carefully before submitting.
Jurisdiction: Intended for U.S. federal proceedings. Filing rules may vary by individual court.
Source: Published by US Dept. of Labor — Forms. View on official site →
Important: Verify the form is current with the issuing authority before filing. The wrong version may delay or void your petition.
When to call a lawyer: Consult a licensed attorney if you’re unsure whether this is the right form or how to fill it out.
Form text
Extracted from the official PDF
Case Name:
Case No: OWCP No:
STIPULATIONS
1. The LHWCA, 33 USC § 901 et seq., as amended, applies to this claim.
2. The Claimant injured his/her on .
3. The injury occurred at .
4. The injury arose out of and in the course of the worker's employment with the Employer.
5. There was an Employer/Employee relationship at the time of the injury(ies).
6. The Employer was timely notified of the injury(ies).
7. The claim was timely filed.
8. The Notice of Controversion was timely filed.
9. The District Director's Informal Conference was conducted on .
10. The worker's average weekly wage at time of injury(ies) was .
11. Compensation has been paid as follows (specify whether TTD, TPD, PTD, PPD*):
WEEKLY COMPENSATION
TYPE DATES RATE
a. from to at
b. from to at
c. from to at
d. from to at
12. Medical benefits have been paid in the total amount of .
13. The worker has been disabled as follows (specify whether TTD, TPD, PTD, PPD*):
TYPE DATES
a. from to
b. from to
c. from to
d. from to
14. The worker reached maximum medical improvement on .
15. The worker returned to his/her usual job as a on .
16. The worker has not returned to his/her usual job.
17. The worker has engaged in alternative employment as follows:
EMPLOYER DATES PAY RATE
a. from to at
b. from to at
18. OTHER
a.
b.
c.
d.
19. Unresolved issues to be adjudicated:
a.
b.
c.
d.
e.
f.
g.
h.
FOR THE CLAIMANT FOR THE EMPLOYER
/s/ /s/
Printed Name Printed Name
FOR THE DIRECTOR FOR THE CARRIER
/s/ /s/
Printed Name Printed Name
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