This form contains 80 fields organized into 18 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Agreement Details
Year	Text	Enter the year relevant to this agreement and undertaking. This should be a four-digit year. Max length: 4 characters
Certificate Information
Number of Certificate	Text	Enter the certificate number associated with the insurance carrier's authorization.
Number of Certificate	Text	Enter the certificate number associated with the insurance carrier's authorization.
Number of Certificate	Text	Enter the certificate number associated with the insurance carrier's authorization.
Company Information
Company Name	Text	Enter the name of the insurance company seeking authorization. Max length: 60 characters
Contact Information
Name	Text	Enter the name of the insurance carrier or the authorized representative. Maximum length is 50 characters. Max length: 50 characters
Street address line 1	Text	Enter the first line of the street address for the insurance carrier or the authorized representative. Maximum length is 24 characters. Max length: 24 characters
Street address line 2	Text	Enter the second line of the street address for the insurance carrier or the authorized representative. Maximum length is 24 characters. Max length: 24 characters
City	Text	Enter the city for the insurance carrier or the authorized representative. Maximum length is 20 characters. Max length: 20 characters
Zip Code (nnnnn-nnnn)	Text	Enter the zip code in the format nnnnn-nnnn for the insurance carrier or the authorized representative. Maximum length is 10 characters. Max length: 10 characters
Date of Agreement
Month	Text	Enter the month when the agreement is being completed. Max length: 20 characters
Year	Text	Enter the year when the agreement is being completed. Max length: 4 characters
Day	Text	Enter the day of the month when the agreement is being completed. Max length: 10 characters
Month	Text	Enter the month when the agreement is being completed. Max length: 20 characters
Year	Text	Enter the year when the agreement is being completed. Max length: 4 characters
Day	Text	Enter the day of the month when the agreement is being completed. Max length: 10 characters
Month	Text	Enter the month when the agreement is being completed. Max length: 20 characters
Financial Information
Currency	Text	Enter the currency amount for the indemnity bond.
Name of Surety Company	Text	Enter the name of the surety company providing the indemnity bond. Maximum length is 50 characters. Max length: 50 characters
Currency	Text	Enter the currency amount for the letter of credit.
Name of Financial Institution	Text	Enter the name of the financial institution issuing the letter of credit. Maximum length is 50 characters. Max length: 50 characters
Currency	Text	Enter the total currency amount deposited as security.
Where Deposited	Text	Enter the location where the security deposit is held. Maximum length is 50 characters. Max length: 50 characters
Currency	Text	Enter the currency value for the par value of the security.
Currency	Text	Enter the currency value for the deposit value of the security.
Percent	Text	Enter the interest rate percentage for the security. Max length: 5 characters
Date (mm/dd/yyyy)	Text	Enter the due date of the security in the format mm/dd/yyyy.
Currency	Text	Enter the currency value for the par value of the security.
Currency	Text	Enter the currency value for the deposit value of the security.
Percent	Text	Enter the interest rate percentage for the security. Max length: 5 characters
Date (mm/dd/yyyy)	Text	Enter the due date of the security in the format mm/dd/yyyy.
Form Actions
Print	Button	Click this button to print the form.
Reset	Button	Click this button to reset the form fields.
Check one or more	CheckBox	Check this box if applicable.
Check one or more	CheckBox	Check this box if applicable.
Form Information
topmostSubform[0].Page1[0].FormName[0	Text	This field displays the form name, which is 'ls-275ic'. No input is required.
topmostSubform[0].Page1[0].ProgramName[0	ComboBox	Select the appropriate program name from the dropdown list. Options include BL, OLMS, WH, DFEC, EEOICP, LS, OWCP, and OFCCP. BL OLMS WH DFEC EEOICP LS OWCP OFCCP
General Information
Check one or more	CheckBox	Select one or more options as applicable.
Check one or more	CheckBox	Select one or more options as applicable.
Help
topmostSubform[0].Page1[0].btnQA[0	Button	Click this button to access the Q&A section for additional help or information.
Identification Information
Enter sequence number	Text	Enter the sequence number, up to 20 characters. Max length: 20 characters
Enter EIN	Text	Enter the Employer Identification Number (EIN), up to 20 characters. Max length: 20 characters
Insurance Carrier Information
Name	Text	Enter the full name of the insurance carrier seeking authorization. This should be the official name as registered. Max length: 60 characters
Issuer Information
Issued By	Text	Enter the name of the entity that issued the security. Max length: 50 characters
Issued By	Text	Enter the name of the entity that issued the security. Max length: 50 characters
Location Information
State Code	ComboBox	Select the state code from the provided list. AR FL ID PA SC GU AL NH NJ WV MS VI WY CO OH WA SD WI CA ME PR OR IN MN AK TN HI MT KY AZ KS NM LA VT IL ND VA NE AS NC DE OK CT IA MA TX DC GA MO NV MI NY UT MD RI
State Name	Text	Enter the name of the state where the document is being signed, up to 20 characters. Max length: 20 characters
County Name	Text	Enter the name of the county where the document is being signed, up to 30 characters. Max length: 30 characters
State Name	Text	Enter the name of the state where the agreement is being completed. Max length: 20 characters
County Name	Text	Enter the name of the county where the agreement is being completed. Max length: 30 characters
State Name	Text	Enter the name of the state where the agreement is being completed. Max length: 20 characters
County Name	Text	Enter the name of the county where the agreement is being completed. Max length: 30 characters
Personal Information
Name	Text	Enter the full name of the person completing the agreement. Max length: 60 characters
Location	Text	Enter the location (city or address) where the person completing the agreement resides. Max length: 60 characters
Title	Text	Enter the title or position of the person completing the agreement. Max length: 60 characters
Name	Text	Enter the full name of the person completing the agreement. Max length: 60 characters
Security Details
Currency	Text	Enter the par value of the currency for the first security.
Currency	Text	Enter the deposit value of the currency for the first security.
Issued By	Text	Enter the name of the entity that issued the first security. Maximum length is 50 characters. Max length: 50 characters
Percent	Text	Enter the interest rate (in percent) for the first security. Maximum length is 5 characters. Max length: 5 characters
Date (mm/dd/yyyy)	Text	Enter the due date for the first security in the format mm/dd/yyyy.
Number of Certificate	Text	Enter the certificate number for the first security.
Currency	Text	Enter the par value of the currency for the second security.
Currency	Text	Enter the deposit value of the currency for the second security.
Issued By	Text	Enter the name of the entity that issued the second security. Maximum length is 50 characters. Max length: 50 characters
Percent	Text	Enter the interest rate (in percent) for the second security. Maximum length is 5 characters. Max length: 5 characters
Date (mm/dd/yyyy)	Text	Enter the due date for the second security in the format mm/dd/yyyy.
Number of Certificate	Text	Enter the certificate number for the second security.
Currency	Text	Enter the par value of the currency for the third security.
Currency	Text	Enter the deposit value of the currency for the third security.
Issued By	Text	Enter the name of the entity that issued the third security. Maximum length is 50 characters. Max length: 50 characters
Percent	Text	Enter the interest rate (in percent) for the third security. Maximum length is 5 characters. Max length: 5 characters
Date (mm/dd/yyyy)	Text	Enter the due date for the third security in the format mm/dd/yyyy.
Signing Information
Signing Time (ex. 10am)	Text	Enter the signing time (e.g., 10am). Max length: 60 characters
Day	Text	Enter the day of signing. Max length: 10 characters
Month	Text	Enter the month of signing. Max length: 12 characters
Year	Text	Enter the year of signing. Max length: 4 characters
Official's Title	Text	Enter the title of the official signing the document, up to 60 characters. Max length: 60 characters
Day	Text	Enter the day of the month for the signing date. Max length: 10 characters
Submission
topmostSubform[0].Page1[0].btnSubmit[0	Button	Click this button to submit the completed form to the U.S. Department of Labor's Office of Workers' Compensation Programs.

Form LS-275, Agreement and Undertaking Instructions