Fillable LS-210 Employer Supplementary Report (PDF)

The LS-210 is the official Employer’s Supplementary Report of Accident or Occupational Illness required by the U.S. Department of Labor. It captures detailed information about work‑related injuries, illnesses, or deaths so that employees receive the benefits they are entitled to under the Federal Employees' Compensation Act (FECA).

What Is the LS-210 Form?

The LS-210 collects data such as the employee’s name, employer details, incident description, medical treatment dates, and the nature of the injury or illness. Filing this form promptly helps ensure timely processing of compensation claims.

How to Complete the LS-210 Online

Instead of downloading, printing, and scanning, you can fill out the LS-210 directly in your browser:

1. Click the "Fill out this form" button on this page.
2. Wait a few seconds while the Formize PDF Filler app loads.
3. Enter the required information into each fillable field. The form automatically validates dates and numeric entries.
4. Use the built‑in e‑signature tool to sign the document with your mouse or finger.
5. When finished, click "Save & Download" to store a copy, or choose "Submit" to send it directly to the designated DOL portal.

Common Mistakes to Avoid

• Leaving fields blank – every required box must be completed; otherwise the form will be rejected.
• Incorrect dates – use the MM/DD/YYYY format and double‑check the incident and treatment dates.
• Mismatched employee IDs – the OWCP number must match the employee’s record.
• Illegible signatures – the digital signature tool ensures a clear, legal signature.

Where to Submit the Completed Form

After saving a PDF copy, you can:

• Upload it to the Department of Labor’s online portal.
• Mail it to the address listed in the form instructions.
• Keep a secure digital copy for your records.

Using Formize’s secure cloud storage keeps your data safe and easily accessible for future reference.