Louisiana Workers Compensation Forms and Resources

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Workers Compensation Forms Provided by the Louisiana Office of Workers Compensation

Form LWC-WC 1002 - Notice of Payment

    • This form is to be completed by the Employer/Insurer and sent to the injured employee, whenever a payment or medical benefits are initiated, modified, suspended or terminated, or controverted.
    • A Notice of Agreement (included on the Form 1002) may filed by the employee or the employee's representative.

Form LWC-WC 1003 - Stop Payment

    • This form is sent by the Employer/Insurer to the injured workers and the OWCA within 30 days of the closure of a case.
    • An amended copy is required if the case re-opens or additional costs are incurred.

Form LWC-WC 1004 - Request for Social Security Benefits Information

    • This form is used to gather information from the Social Security Administration and to calculate the amount of any offset to workers compensation.
    • Pursuant to Louisiana Revised Statute (L.R.S.) 23:1225 (A) or (C) of the Louisiana Workers' Compensation Act, an employer and/or its insurer may have the right to reduce an employee's workers' compensation wage benefits because the employee is receiving additional benefits from another source, such as the Social Security Administration. 

Form LWC-WC 1005A - Motion for Recognition of Right to Social Security Offset

    • This Motion is used by the employer/insurer to request recognition of the right to take an offset for Social Security Disability (SSDI) benefits.
    • The employer/insurer requests in this Motion that the workers compensation Judge enter an order recognizing the employer/insurer's right to take the reverse offset, since the employee is receiving Permanent Total Disability (PTD) benefits in addition to Social Security Disability (SSDI) benefits.

Form LWC-WC 1005B - Order Recognizing Right to Social Security Offset

    • This Order is to be signed by the workers compensation Judge recognizing an entitlement to a social security offset.
    • The workers compensation Judge may enter this order recognizing the employer/insurer's right to take the reverse offset, since the employee is receiving Permanent Total Disability (PTD) benefits in addition to Social Security Disability (SSDI) benefits.

Form LWC-WC 1006 - Subpoena & Subpoena Duces Tecum

    • This series of forms is issued to compel an individual to appear for a deposition or to give testimony, or to produce documentation.

Form LWC-WC IA-1 - Employer's First Report of Injury or Illness 

    • This form requires employers to complete and forward to their workers compensation insurance carrier or self- insured fund.
    • In turn, the insurance carrier, self-insured fund or self-insured employer is then obligated to enter the form as per instructions on the Louisiana Workforce Commission (LWC) Electronic Data Interchange (EDI) Website.
    • This form replaces the prior Form 1007, beginning in 2014.

Form LWC-WC 1008 - Disputed Claim for Compensation

    • Form to be filed with the Workers Compensation district office when there is any disputed issue in a claim, such any dispute over wage benefits, medical benefits, choice of physician, disability status, vocational rehabilitation, offsets or credits, or an Independent Medical Examination (IME).
    • The filing party may attach a letter or petition with additional information with this disputed claim or when later amending this disputed claim.
    • The filing party must provide a copy of this claim and any amendment to all opposing parties.

Form LWC-WC 1009 - Disputed Claim for Medical Treatment

    • Form to be filed with the Workers' Compensation Medical Services Director when there is a Disputed Claim for Medical Treatment.
    • This request will not be honored unless there are medical services in dispute as per La. R.S. 23:1203.1 J, and the following have all occurred:
      • The insurer has issued a denial.
      • The insurer has issued an approval with modification.
      • The insurer's failure to act has resulted in a deemed denial.
      • The aggrieved party is seeking a variance from the medical treatment schedule.
    • Disputes relating to compensability and/or causation are not addressed by the medical director.
    • The completed LWC-WC-1009 must be submitted to OWCA within 15 calendar days of the 1010 denial, 1010 approval w/modification or 1010 deemed denial.
    • The following records/documents must be attached to this request. Failure to do so may result in the rejection of the request by the OWCA Director:
      • A copy of the LWC-WC-1010.
      • All of the information previously submitted to the carrier/self-insured employer.
      • Include scientific medical evidence when seeking a variance.
      • If applicable, a copy of the denial letter issued by the insurance carrier.

Form LWC-WC 1010 - Request of Authorization/Carrier or Self-Insured Employer Response

    • This form constitutes a request of authorization for medical treatment, and the response of the insurance company or self-insured employer.

Form LWC-WC 1010A - First Request

    • This First Request form constitutes the response of the insurance company or self-insured employer to a request of authorization for medical treatment by the employee.
    • This First Request form indicates that the insurance company has received a request for authorization for the above-referenced matter and have determined it lacks the required minimum information.

Form LWC-WC 1011 - Request for Compromise or Lump Sum Settlement

    • This form is filed with OWCA to request the review and approval of a compromise or lump sum settlement agreement.
    • This form must be submitted and filed with every full and final workers compensation compromise or settlement.

Form LWC-WC 1015 - Request for Independent Medical Examination (IME)

    • This form is to be completed by any party requesting an Independent Medical Examination (IME).

Form LWC-WC 1017A - Glossary of Terms for Form 1017A

    • This form is a glossary of terms used when completing form a LWC-WC 1017A Quarterly Report of Injury/Illness.

Form LWC-WC 1020 - Employee's Monthly Report of Earnings

    • This form is to be filed monthly with the employer's insurer by the injured worker to report any earnings.
    • The employee must submit this report to the insurer within 30 days of a job-related injury, and every 30 days as long as the employee receives workers compensation indemnity benefits.
    • The employee's lost wage benefits may be suspended if the employee does not timely submit this report.

Form LWC-WC 1020 (en Español) - Reporte Mensual de Ganancias Del Empleado

    • This form is a Spanish language version of a Form LWC-WC 1020 Employee's Monthly Report of Earnings.

Form LWC-WC 1021 - Cost Containment Application

    • This form is an employer's application for participation in the cost containment program.

Form LWC-WC 1025 (en Español) - Certificado de Conformidad Del Trabajador

    • This form is a Spanish language version of a Form LWC-WC 1025 Employee's Certificate of Compliance.

Form LWC-WC 1025.EE - Employee's Certificate of Compliance

    • This form is to be filed by injured workers explaining rights and responsibilities while receiving workers compensation benefits and penalties for failure to comply.
    • The employee must submit this form to the insurance company within 14 days of its receipt, or the employee's benefits may be suspended.

Form LWC-WC 1025.ER - Employer's Certificate of Compliance

    • This form is to be filed by the employer explaining the employer's rights and responsibilities to provide workers' compensation benefits as well as penalties for failure to comply.

Form LWC-WC 1026 - Employee's Quarterly Report of Earnings

    • This form is to be filed quarterly by the injured worker with his or her employer or insurer to report any earnings.
    • The employee must submit this form to the insurance company within 14 days of its receipt, or the employee's benefits may be suspended.

Form LWC-WC 1027 - Request for Waiver of Payment of Advance Costs

    • This form is to be used to determine whether the financial status of an injured worker warrants the waiver of payment of any advanced costs when filing claims.

Form LWC-WC 1121 - Physician Choice Form

    • This form is to be completed by the injured worker when selecting their physician of choice in each field or specialty.

Form LWC-WC 1150 - Workers Compensation Records Request Form

    • This form is to be used to make a Workers Compensation Records Request.

Form LWC-WC 1151 -  Employee Authorization for OWCA to Release Confidential Workers Compensation Records

    • This form is an OWCA form for Employee Authorization to Release Confidential Workers Compensation Records.

Form LWC-WC 3000 - Special Reimbursement Reconsideration Appeal Form

    • This form is to be completed by a medical provider when requesting a reimbursement reconsideration appeal.

SIB Form A - Notice of Claim with Second Injury Board

    • This form is to be completed and submitted by the insurer, self-insured employer, or third party administrator, along with documentation listed on the form with each new claim filed with the Second Injury Board.

SIB Form B - P & I Form

    • This form is to be submitted with each request for reimbursement from the Second Injury Board. 

Medical Services Resources Provided by the Louisiana Office of Workers Compensation

CPT Codes - 2000 Update

    • CPT is a listing of descriptive terms and numeric identifying Current Procedures Terminology codes and modifiers for reporting medical services and procedures performed by physicians and other health care providers.
    • This publication includes only CPT numeric identifying codes and modifiers for reporting medical services and procedures that were selected by the Office of Workers Compensation.

Rehabilitation Services - Louisiana Maximum Fee Schedule, Chapter 7. Rehabilitation Services.

    • This form establishes the guidelines for the rehabilitation of occupationally disabled employees.

Form LWC-WC 3000 - Special Reimbursement Reconsideration Appeal Form

    • This form is to be completed by a medical provider when requesting a reimbursement reconsideration appeal.

Utilization Review Contacts

    • This form identifies the Utilization Review Company for every Louisiana workers compensation insurance company and self-insured employer.

Second Injury Board Resources Provided by the Louisiana Office of Workers Compensation

SIB Form A - Notice of Claim with Second Injury Board

    • This form is to be completed and submitted by the insurer, self-insured employer, or third party administrator, along with documentation listed on the form with each new claim filed with the Second Injury Board.

SIB Form B - P & I Form

    • This form is to be submitted with each request for reimbursement from the Second Injury Board. 

Second Injury Board Knowledge Questionnaire

    • The intent of this questionnaire is for the employee to provide the employer with knowledge about any pre‐existing medical condition or disability which may entitle the employer to reimbursement from the Louisiana Workers Compensation Second Injury Board in the event the employee suffers an on‐the‐job injury,

Second Injury Board Knowledge Questionnaire (Spanish)

    • This form is a Spanish language version of a Second Injury Board Knowledge Questionnaire.

Second Injury Board Rules of Practice and Procedures

    • This form establishes the rules of practice and procedures for reimbursement from the Second Injury Board.

Second Injury Fund Brochure

    • This brochure explains the basic operation of the Second Injury Board. 

Settlement Evaluation

    • This form is to be submitted to the Second Injury Board for approval of a settlement on a claimant who is receiving supplemental earnings benefits.

Settlement Evaluation (Permanent and Total)

    • This form is to be submitted to the Second Injury Board for approval of a settlement on a claimant who has been declared permanently and totally disabled.

Workplace Safety Resources Provided by the Louisiana Office of Workers Compensation

Directory of Safety Services

    • This form is a directory of safety services, as revised in January 2012.

Directory of Safety Services (Consultant Applications)

    • This form is an application to be included in the directory of safety services.

Safety Requirements

    • This form contains the guidelines for implementing a working and occupational safety plan.

Records Management Resources Provided by the Louisiana Office of Workers Compensation

OWC Employee Authorization Form

    • This form is an OWC Employee Authorization to Release Confidential Workers Compensation Records.

OWC Record Request Form

    • This form is an OWC Record Request Form for Confidential Workers Compensation Records.

Fraud Resources Provided by the Louisiana Office of Workers Compensation

Fraud Rules - Title 40, Chapter 19 Rules.

    • These rules outline the guidelines required for compliance with the Workers Compensation Act.

Warning Signs of Workers Compensation Fraud

    • This form outlines signs of Workers Compensation Fraud.

Miscellaneous Resources Provided by the Louisiana Office of Workers Compensation

Admitted Workers Compensation Insurers

    • This form contains a list of admitted Louisiana workers compensation insurance companies, including their contact information.

Authorized Self-Insured Employers

    • This form contains a list of authorized Louisiana workers compensation self-insured employers, including their contact information.

Authorized Third Party Administrators

    • This form contains a list of authorized Louisiana workers compensation third party administrators, including their contact information.

Average Weekly Wage Computation

    • This form contains instructions for computing an employee's average weekly wage.
    • This form also contains the current Mileage Reimbursement Rate, the Minimum Compensation Rate, and the Maximum Compensation Rate cap/limit by year.

Circuit Courts of Appeal

    • This form lists the Circuit Courts of Appeal by parish on a map.

Cost Containment Rules

    • These rules serve as guidelines to establish and implement effective injury control measures.

Derechos y Responsabilidades Para Los Empleados y Los Empleadores en La Compensación a Los Trabajadores

    • This form is a Spanish language version of the Rights and Responsibilities in workers compensation for employees and employers relating to Louisiana's workers compensation entitlement and procedures.

District Offices and Perishes Served

    • This form lists the District Offices and parishes served, including their contact information.

Drug Testing Programs in Job Accident Cases - Title 40. Chapter 15. 

    • These rules serve as guidelines for accident-related drug testing.

Exempt Businesses

    • This form lists the companies exempt from 300 log.

Exemptions from Coverage

    • This form lists the companies exempt from coverage.

Form LWC-WC 1017 - Exemptions by North American Industry Classification System (NAICS) Codes

    • This form lists the exemptions by North American Industry Classification System (NAICS) Codes.

General Provisions - Title 40. Chapter 1. General Provisions.

    • These provisions define the responsibilities and rights of the employee, the employer, and the insurance company in the administration of workers compensation in Louisiana.

Hearing Rules - Office of Workers Compensation

    • These Hearing Rules are the Court Hearing Procedures for Louisiana workers compensation.
    • The purpose of these rules is to govern the practice and procedures before the workers compensation Court which is a statewide court having jurisdiction of claims for workers compensation benefits, the controversion of entitlement to benefits and other relief under the Workers' Compensation Act.
    • These rules are designed to facilitate the equitable, expeditious and simple resolution of workers compensation disputed claims filed with the Court.

Interpreter/ADA Accommodations

    • This form serves as a request for a language interpreter or deaf/hearing impaired assistance in Workers Compensation Court.

Letter of Credit - Irrevocable Letter of Credit

    • This Letter of Credit establishes credit in favor of the Louisiana Workforce Commission, Office of Workers' Compensation Administration.

Mileage Reimbursement

    • This form identifies the mileage reimbursement rates by year for travel mileage reimbursement.

OWC District Boundaries

    • This form establishes the OWC District Boundaries by parish.

Parish Codes for Louisiana

    • This form lists the codes assigned to each parish in Louisiana.

Rights and Responsibilities in Workers Compensation

    • This form establishes the rights and responsibilities in workers compensation for employees and employers relating to Louisiana's workers compensation entitlement and procedures.

Security Agreement for Certificate of Deposit

    • This form provides the documentation outlining conditions and containing required forms.

State of Louisiana Indemnity

    • This form serves as the legal document necessary to guarantee the self-insured's obligation to pay indemnity benefits.

Surety Bond

    • This form serves as the legal document necessary when making an application to become self-insured.

What is Workers Compensation Fraud?

    • This form defines Workers Compensation Fraud.

Louisiana Revised Statutes and Laws in Louisiana Workers Compensation

The Louisiana laws that govern workers compensation are known as Revised Statutes, and can be found here:

Social Security Disability, Medicare and Other Resources Related to Louisiana Workers Compensation

Social Security Disability (SSDI) resources can be found here:

Resources from the Centers for Medicare & Medicaid Services can be found here:

The Occupational Safety and Health Administration (OSHA) resources can be found here:

Workers Compensation resources at the United States Department of Labor can be found here:

Other resources from organizations that advocate for the rights of employee's can be found here:

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