DOL Form LS-426

View OWCP-DLHWC's Form LS-426 Online htm
Agency: OWCP-DLHWC
Title: DLHWC (Longshore) LS-426, Request for Earnings Information
Form Description: DLHWC (Longshore) LS-426, Request for Earnings Information: This is a Department of Labor letterhead letter sent by the Longshore District Office to an injured worker to request information regarding earnings for the one year prior to the injury.� The form is sent when the Department of Labor receives information from an insurance carrier or self insured employer that compensation is being paid at the minimum rate pending receipt of earnings information.
OMB Control Number: 1240-0025