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E-mail This PageDOL Form LS-265
| Agency: | OWCP-DLHWC |
| Title: | DLHWC (Longshore) LS-265, Certification of Funeral Expenses |
| Form Description: | DLHWC (Longshore) LS-265, Certification of Funeral Expenses: This form is submitted by the provider of funeral services to notify the Department of Labor and self-insured employer/insurance carrier of the costs of funeral services for a deceased employee. It is used to determine the amount of funeral expenses allowable in a death case, subject to the maximum allowable. |
| OMB Control Number: | 1240-0040 |
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