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Louisiana Form Center -

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Form

Description

IA-1.pdf Employers First Report of Injury or Illness - (1007 replacement - voluntary for 2013 & mandatory beginning 1/1/2014) - This form requires employers to complete and forward to their workers' compensation insurance carrier or self- insured fund.)
1000form.pdf Annual Report of Workers' Compensation Costs
1002form.pdf Notice of Payment
1003form.pdf Stop Payment
1004form.pdf Request for Social Security Benefits Information
1005a.pdf Motion for Recognition of Right to Social Security Offset
1005b.pdf Order Recognizing Right to Social Security Offset
1006form.pdf Subpoena and Subpoena Duces Tecum
1008form.pdf Disputed Claim for Compensation
1009form.pdf Disputed Claim for Medical Treatment
1010.pdf Request of Authorization / Carrier or Self Insured Employer Response
1010A.pdf First Request
1011form.pdf Request for Compromise of Lump Sum Settlement
1015form.pdf Request for Independent Medical Exam
1020form.pdf Employee Monthly Report of Earnings
1020form_sp.pdf Employee Monthly Report of Earnings (Spanish)
1021form.pdf Cost Containment Application
1025ee.pdf Employee Certificate of Compliance
1025er.pdf Employer Certificate of Compliance
1025form_sp.pdf Employer Certificate of Compliance (Spanish)
1026form.pdf Employee's Quarterly Report of Earnings
RWAC.pdf 1027 - Request for Waiver of Advance Costs
1121form.pdf Physician Choice Form
2005form.pdf Self-Insurer Application
Form2005_chklist.pdf Self-Insurer Application Checklist
form3000.pdf Special Reimbursement Consideration Appeal
sibknowledge.pdf LA OWCA Second Injury Board Knowledge Questionnaire
sibknowledge-sp.pdf LA OWCA Second Injury Board Knowledge Questionnaire (Spanish)
sibforma.pdf Notice of Claim with Second Injury Fund
piform.pdf P & I Form
settlementevaluation.pdf Settlement Evaluation
settlementevaluationPT.pdf Settlement Evaluation-Permanent and Total
certificateofdeposit.pdf Security Agreement for Certificate of Deposit
IGA.pdf Indemnity and Guaranty Agreement
OWCAInterpreter.pdf Interpreter/ADA Accomodations
sca.pdf Service Company Application
sca_checklist.pdf Service Company Application Checklist
SIB-EFT.pdf Electronic Funds Transfer Enrollment Form
suretybond.pdf Surety Bond
poster.pdf POSTER - Workers' Compensation Poster
poster_sp.pdf POSTER - Workers' Compensation Poster (Spanish)
fraudposter.pdf POSTER - Fraud Poster
rights_and_responsibilities.pdf Rights and Responsibilities in Workers' Compensation
rights_and_responsibilities_spanish.pdf Rights and Responsibilities in Workers' Compensation (Spanish)