Request for Intervention

Request for Intervention                                                            U.S. Department of Labor
                                                                                    Office of Workers' Compensation Programs



You must use this form to request intervention from the Office of Workers' Compensation Longshore                   OMB No.: 1240-0058
Program. The District Suboffice has discretion on what action to take based on the request and                      Expires: 04/30/2029
documentation in the file. You must send a copy of the completed form to all parties and their
representatives.
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. Type of Intervention Requested (OWCP reserves the right to make a final determination)
                                           Non-Conference               Informal Conference

6. Employer                                                             7. Insurance Carrier
8. Name, Address and Phone Number of Party Requesting Intervention


9. Briefly state the facts of the claim:




10. List the issues the parties have reached agreement on:




11. Check Issues Requiring Intervention and attach position paper with supporting documents:

                   Occurrence of Injury                             Temporary Disability

                   Responsible Employer/Carrier                     Permanent Disability

                   Jurisdiction/Situs/Status                        Medical

                   Average Weekly Wage                              Special Fund Modification

                   Additional Compensation                          Other

12. Describe efforts made to resolve issue(s):




As verified by the signature below, this form was sent to all opposing parties and their representatives
13. Print Name                                     14. Signature                                     15. Date (Month, Day, Year)



                                                            Print           Reset                                                  Form LS-7
                                              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 intervention by the Office of Workers’ Compensation Longshore Program.
    See 20 C.F.R. 702.301, 702.311. 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-7 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 collected, which includes a list of disputed issues between the parties to the
    compensation claim, will be used to determine whether and what level of intervention by the Office of Workers’
Compensation Longshore Program would help resolve the disputed issues. (3) Completion of this form is required to
request intervention 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); any other entity that may be liable for
    the payment of compensation; 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 processing of the claim,
 the payment of benefits, or may result in an unfavorable decision or reduced level of benefits. (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-7
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