Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS
A lock () or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.

Agreement and Undertaking (Self-Insured Employer)

Form ID:

OWCP LS-275si

Control ID:

OMB No. 1240-0005

Expiration date:

Mon, 30 Nov 2026 - 23:59

Forms

OWCP LS-275si: Agreement and Undertaking (Self-Insured Employer)