NOTE: THIS REQUEST WILL NOT BE HONORED UNLESS A DISPUTE HAS ARISEN AS TO CONDITION OF THE EMPLOYEE AS PER L. R.S. 23:1123 7. This form is submitted by:
‘ Employee ‘ Employer ‘ Insurer ‘ TPA/Self Insurance Fund
A. The choice of the medical practitioner shall be that of the Director of the Office of Workers' Compensation as per L. R. S. 23:1123.
B. A cover letter outlining the conflicting medical issue(s) in dispute (reason for request) along with the conflicting medical reports must be attached to this form.
C. A list of names, addresses, phone numbers and reports of all physicians/medical providers who have treated or examined the injured employee for this injury must be included. Indicate who chose each health care provider.
D. A copy of this request must be mailed to all parties.
EMPLOYEE EMPLOYEE'S ATTORNEY
8. Name 9. Name
Street or Box Street or Box
City City
State Zip State Zip
Phone ( ) Phone ( )
EMPLOYER INSURER / ADMINISTRATOR
( circle one )
10. Name 11. Name
Street or Box Street or Box
City City
State Zip State Zip
Phone ( ) Phone ( )
EMPLOYER / INSURER'S ATTORNEY ( circle one )
12. Name Street or Box City
State Zip
Signature of Applicant Date
Phone ( )
AUTHORITY NOTE: Promulgated in accordance with R.S.
23:1310.1.
HISTORICAL NOTE: Promulgated by the Department of Labor, Office of Workers' Compensation Administration, LR 25:301 (February 1999).
§6655. Employer’s Report of Occupational Injury &
Illness Quarterly Summary; Form LDOL-WC-1017A
Mail To:
Office of Workers’Compensation Safety & Health Section P.O. Box 94040 Baton Rouge LA 70804-9040
********************
COMPANY: Safety and Health Section
ADDRESS:
(504) 342-7556
EMPLOYER’S REPORT OF OCCUPATIONAL INJURY & ILLNESS QUARTERLY SUMMARY
*THIS FORM MUST BE SUBMITTED TO THE OFFICE OF WORKERS COMPENSATION ADMINISTRATION BY EVERY EMPLOYER SUBJECT TO RECORDKEEPING REQUIREMENTS UNDER THE LOUISIANA REVISED STATUTES TITLE 23. THIS REPORT IS DUE BY THE LAST DAY OF THE 1ST MONTH OF THE SUCCEEDING QUARTER.
UC REPORTING NO REPORTING UNIT NO PARISH CODE QUARTER YEAR
SIC CODE
NATURE OF BUSINESS: TELEPHONE ( )
READ GLOSSARY BEFORE COMPLETING REPORT
1. TOTAL NUMBER OF EMPLOYEES(FULL AND PART TIME) REFER TO GLOSSARY OF TERMS ITEM7 CURRENT SAME QTR. CURRENT PREVIOUS
QUARTER PREVIOUS YR. YEAR-TO- YEAR-END
DATE TOTALS
2. TOTAL MANHOURS WORKED –REFER TO GLOSSARY ITEM9AND ITEM4NOTEœ
3. MEDICAL TREATMENT CASES •REFER TO GLOSSARY ITEM11AND ITEM4NOTE•
4. LOST TIME WORK DAYS •REFERTO GLOSSARY ITEM12œ
5. RESTRICTED WORK DAYS •REFER TO GLOSSARY ITEM11AND ITEM4NOTEœ
6. FATALITIES(DEATHS) •REFER TO GLOSSARY ITEM12œ
7. TOTAL RECORDABLE CASES •LINES2 + 4 + 5 + 6 =LINE7œ
8. LOST TIME WORK DAYS •DAYS ASSOCIATED WITH CASE FROM LINE4,SEE GLOSSARY.ITEM14AND15NOTEœ
9. RESTRICTED WORK DAYS •DAYS ASSOCIATED WITH CASES FROM LINE5,SEE GLOSSARY.ITEM15
10. TOTAL MEDICAL TREATMENT CASE RATE •USE TOTAL CASES FROM LINE3,SEE GLOSSARY.ITEMS16, 17AND18œ
11. TOTAL LOST TIME WORK CASE RATE •USE TOTAL CASES FROM LINE4,SEE GLOSSARY.ITEMS16,17AND18œ
12. TOTAL RESTRICTED WORK CASE RATE USE TOTAL CASES FROM LINE5,SEE GLOSSARY.ITEMS16,17AND18œ
13. TOTAL RECORDABLE CASE RATE •USE TOTAL CASES FROM LINE6,SEE GLOSSARY.ITEMS16, 17AND18œ
14. TOTAL LOST TIME WORK DAY RATE •USE TOTAL CASES FROM LINE7,SEE GLOSSARY.ITEMS16, 17AND18œ
15. TOTAL RESTRICTED WORK DAY RATE •USE TOTAL CASES FROM LINE8,SEE GLOSSARY.ITEMS16, 17AND18œ
16. TOTAL NUMBER OF RECORDABLE ACCIDENT INVESTIGATIONS IN WRITING THIS QUARTER THAT WERE REVIEWED AND/OR COMMUNICATED WITH EMPLOYEES.
16A. WHAT WERE THE BASIC CAUSE(S)OF EACH INJURY/ILLNESS NOTED IN ITEM16?
16B. WHAT CORRECTIVE ACTION WAS TAKEN OR IS PLANNED TO ELIMINATED OR CONTROL HAZARD(S)THAT WERE IDENTIFIED IN16A?
17. DOES YOUR FACILITY HAVE AN*ATTENDANT(EMPLOYEE)TRAINED IN FIRST AID AND A FIRST AID KIT? (*SEE GLOSSARY,ITEM NO. 2) ___Yes ___No
18. DOES YOUR FACILITY NEED SAFETY CONSULTATION OR SAFETY PROGRAM DEVELOPMENT ASSISTANCE FROM THE OFFICE OF WORKERS’COMPENSATION? ___Yes ___No 19. REPORT PREPARED BY:
____________________ ____________________ ____________________
20. REPORT REVIEWED AND APPROVED BY:
__________________________________ _____________________________________
please type or print name signature of facility
21. REMARKS/COMMENTS. THIS SPACE MAY BE USED TO RECORD CASE CHANGES. (I.E.,MEDICAL CASES IN JANUARY WHICH LATER CHANGES IN APRIL TO A RESTRICTED WORKCASE OR LOST TIME CASE,OR OTHER RELEVANT INFORMATION).
________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
22. DATE OR THIS REPORT. WORKERS’COMPENSATION INSURER:
______________ _____________________________________________________________
Name of workers’compensation insurer & telephone number with area code 23. MONTHLY SUMMARY CHART FOR THE CURRENT QUARTER: (SEE GLOSSARY,ITEM19C)
MONTH MANHOURS MEDICAL LOST TIME RESTRICTED FATALITIES RECORD-ABLE LOST TIME RESTRICTED MEDICAL TREATMENT WORK CASE WORK DAY WORK DAY RECORDED
WORKED TREATMENT CASES WORK CASES (DEATHS) WORK DAYS WORK DAYS WORK DAYS
TOTAL MEDICAL RESTRICTED LOST TIME RESTRICTED TOTAL
CASES CASE RATE RATE RATE RATE CASES
AUTHORITY NOTE: Promulgated in accordance with R.S.
23:1310.1.
HISTORICAL NOTE: Promulgated by the Department of Labor, Office of Workers' Compensation Administration, LR 25:302 (February 1999).
§6657. Employee’s Monthly Report of Earnings; Form LDOL-WC-1020
EMPLOYEE’S MONTHLY REPORT OF EARNINGS You must submit this report to your employer’s workers’compensation insurer within 30 days of your job-related injury, and every 30 days thereafter as long as you receive workers’ compensation indemnity disability benefits. You do not have to submit this report if you have only receiv ed medical benefits. Your worker’s compensation benefits may be suspended if you do not timely submit this report.
DO NOT leave any blanks on this Report. Print or type all responses, and use N/A (not applicable) or -0- (zero) where appropriate.
1. The information in this Report is true for the period beginning
, 19 and ending , 19 .
2. The name and address of the employer that I am receiving benefits
from is: .
3. Did you work for this employer in the past 30 days? . If yes, how much were your gross wages? $ . 4. Did you work for any other employer in the past 30 days?
If yes, the name and address of the employer is . If yes, how much were your gross wages?
.
5. Did you have any earnings through self employment in the past 30 days? If yes, how much? $
6. Did you receive any unemployment compensation benefits in the past
30 days? If yes, how much? $ .
7. I received $ in old age insurance benefits under Title II of the Social Security Act.
8. I received $ in Social Security Disability Benefits or other disability benefits.
EMPLOYEE CERTIFICATION
I certify that I can read the English language, that I have read this entire docum ent and understand its contents, and that I understand I am held responsible for this information. I certify my answers are complete and true, and certify y compliance with the Louisiana Worker’s Compensation Act.
Print Name Signature Social Security Number ( )
Address City State/Zip Phone Number
Employer Name Date
AUTHORITY NOTE: Promulgated in accordance with R.S.
23:1310.1.
HISTORICAL NOTE: Promulgated by the Department of Labor, Office of Workers' Compensation Administration, LR 25:304 (February 1999).
§6659. Employee and Employer Certificate of Compliance; Form LDOL-WC-1025.EE
EMPLOYEE
CERTIFICATE OF COMPLIANCE
You must submit this form to your employer's workers' compensation insurer or to your employer within 14 days of its receipt. Your workers' compensation benefits may be suspended if you do not timely submit this Certification. You would be entitled to all suspended benefits after this Certification is provided to your insurer, if you are otherwise eligible for benefits.
It is unlawful for you to work and receive workers' compensation indemnity disability, except for supplemental earnings benefits. Supplemental earnings benefits are paid when an employee is able to work, but is unable to earn 90% or more of his pre-injury wages as a result of a job related accident. As an injured worker, you must notify your employer or insurer of the earning of any wages, changes in employment or medical status, receipt of unemployment benefits, receipt of social security benefits and receipt of retirement benefits. If you receive benefits for more than 30 days, you will be required to certify your earnings to your insurer quarterly.
It is unlawful for you to receive workers' compensation indemnity disability benefits and unemployment benefits at the same time, except for permanent partial disability benefits. Permanent partial disability benefits are paid solely for amputation or for anatomical loss of use of a body part or function. If you violate this provision, you may be fined up to $10,000, imprisoned up to 90 days, or both.
It is unlawful for you to willfully make, or to assist or counsel someone else to make, a false statement or representation in order to obtain or to defeat workers' compensation benefits. If you violate this provision, you may be fined, imprisoned, or both, as follows:
Unlawful Benefits Fine Imprisonment
$10,000 or more up to $10,000 up to 10 years, with or without hard labor
$2,500 or more but less
than $10,000 up to $ 5,000 up to 5 years, with or without hard labor
less than $2,500 up to $500 up to 6 months
In addition to these criminal penalties, you may be assessed a civil penalty of up to $5,000 and may forfeit your right to receive workers' compensation benefits.
EMPLOYEE CERTIFICATION
I certify that I can read the English language, that I have read this entire document and understand its contents, and that I understand I am held responsible for this information. I certify my compliance with the Louisiana Workers' Compensation Act.
Print Name Signature Social Security Number Date
( )
Address City State / Zip Phone Number
Note: Only one copy is required per case from the employee.
EMPLOYER
CERTIFICATE OF COMPLIANCE
You must submit this certification to your workers’compensation insurer. Failure to submit this Certification as required may result in your being penalized by a fine of $500, payable to your insurer.
You must secure workers’compensation for your employees through insurance or by becoming an authorized self-insurer. If you fail to provide security for workers’compensation, you must pay an additional 50% in weekly benefits to your injured workers.
If you willfully fail to provide security for workers’compensation, then you are subject to a fine of up to $10,000, imprisonment with or without hard labor for not more than 1 year, or both. If you have been previously fined and again fail to provide security for workers’compensation, then you are subject to additional penalties, including a court order to cease and desist from continuing further business operations.
You must not collect, demand, request, or accept any amount from any employee to pay or reimburse for the workers’compensation insurance premium. If you violate this provision, you may be punished with a fine of not more than $500, or imprisoned with or without hard labor for not more than one year, or both.
It is unlawful for you to willfully make, or to assist or counsel someone else to make, a false statement or representation in order to obtain or to defeat workers’compensation benefits. If you violate this provision, you may be fined up to $10,000, imprisoned with or without hard labor for up to 10 years, or both depending on the amount of benefits unlawfully obtained or defeated. In addition to these criminal penalties, you may be assessed a civil penalty of up to $5,000.
EMPLOYER CERTIFICATION
I certify that I can read the English language, that I have read this entire document and understand its contents, and that I understand I am held responsible for this information. I certify my compliance with the Louisiana Workers' Compensation Act.
Preparer Name (PRINT) Signature Date
Company Name Company Address
( )
Phone Number Insurance Policy Number
Employee Name Employee Social Security Number
LDOL-WC-1025.ER
AUTHORITY NOTE: Promulgated in accordance with R.S.
23:1310.1.
HISTORICAL NOTE: Promulgated by the Department of Labor, Office of Workers' Compensation Administration, LR 25:305 (February 1999).
§6661. Employee’s Quarterly Report of Earnings; Form LDOL-WC-1026
EMPLOYEE'S QUARTERLY REPORT OF EARNINGS
You must submit this Report to your workers' compensation insurer within 14 days. Your workers' compensation benefits may be suspended if you do not timely submit this Report. You would be entitled to all suspended benefits after this report is provided to your Insurer, if you are otherwise eligible for benefits.
You do not have to file this report if you have timely filed all necessary LDOL-WC-1020 forms, or if you have only received medical benefits.
DO NOT leave any blanks on this Report. Print or type all responses, and use N/A (not applicable) or -0- (zero) where appropriate.
1. The information in this Report is true for the period beginning , 19 and ending , 19___
2. The name and address of the employer that I am receiving benefits from is:
3. Did you work for this employer in the past quarter?
If yes, how much were your gross wages? $
4. Did you work for any other employer in the past quarter? If yes, the name and address of the employer is If yes, how much were your gross wages? $ 5. Did you have any earnings through self employment in the past quarter? If yes, how much? $
6. Did you receive any unemployment compensation benefits in the past quarter? If yes, how much? $ 7. I received $ in old age benefits under Title ll of the Social Security Act.
8. I received $ in Social Security Disability Benefits or other disability benefits.
EMPLOYEE CERTIFICATION
I certify that I can read the English language, that I have this entire document and understand its contents, and that I understand I am held responsible for this information. I certify my answers are complete and true, and certify my compliance with the Louisiana Workers' Compensation Act.
PRINT NAME SIGNATURE SOCIAL SECURITY NUMBER
( )
ADDRESS CITY STATE / ZIP PHONE NUMBER
EMPLOYER NAME DATE
AUTHORITY NOTE: Promulgated in accordance with R.S.
23:1310.1.
HISTORICAL NOTE: Promulgated by the Department of Labor, Office of Workers' Compensation Administration, LR 25:307 (February 1999).
Inquiries concerning the proposed repeal and enactment may be directed to: Dan Boudreaux, Assistant Secretary, Office of Workers’ Compensation Administration, Louisiana Department of Labor, P.O. Box 94094, Baton Rouge, Louisiana 70804-9094.
Interested persons may submit data, views, arguments, information or comments on the proposed repeal and enactme nt in writing, to the Louisiana Department of Labor, P.O. Box 94094, Baton Rouge, Louisiana 70804-9094, Attention: Dan Boudreaux, Assistant Secretary, Office of Workers’Compensation Administration. Written comments must be submitted and received by the Department within 10 days from the date of this notice. A request pursuant to R.S.
49:953(A)(2) for oral presentation, argument or public hearing must be made in writing and received by the Department within 20 days of the date of this notice.
Garey Forster Secretary of Labor
9902#018
RULE of oil and gas. Also referred to as Oil and Gas Activity.
Department of Natural Resources Office of the Secretary Oyster Lease Damage Evaluation Board Proceedings (LAC 43:I.Chapters 37 and 39)
The Department of Natural Resources, Office of the Secretary hereby adopts the following rule governing the administration of the Oyster Lease Damage Evaluation Board, in accordance with R.S. 56:700.10 et seq., and the Administrative Procedure Act, R.S. 49:950 et seq.
Title 43
NATURAL RESOURCES