Workers' Compensation

• Forms - Numerical
• Fraud
• Medical Services
• Records Management
• Second Injury Board
• Workplace Safety
• Miscellaneous

Please visit the Downloads Main Menu to view information about the file formats used and where to download the applications needed to view these formats.

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Forms - Numerical

Name	Format	Size	Description
Annual Report of Workers' Compensation Costs			LWC-WC 1000 - This Workers' Compensation page provides an annual report of Workers' Compensation costs.
Notice of Payment - Form 1002		165 KB	LWC-WC 1002 - Form to be completed by the Employer/Insurer and sent to the injured employee.
Stop Payment - Form 1003		54 KB	LWC-WC 1003 - Form is sent by the Employer/Insurer to the injured workers and OWCA.
Request for Social Security Benefits Information			LWC-WC 1004 - Form used to gather information from the Social Security Administration and to calculate the amount of any offset (Workers' compensation)
Motion for Recognition of Right to Soc. Sec. Offset - Form 1005a		18 kb	LWC-WC 1005A - Form used by the employer/insurer to request recognition of right to take an offset for social security benefits (Workers' compensation)
Order Recognizing Right to Soc. Sec. Offset - Form 1005b		19 kb	LWC-WC 1005B - Order signed by the workers’ compensation judge recognizing entitlement to a social security offset
Subpoena & Subpoena Duces Tecum - Form 1006		107KB	LWC-WC 1006 - Series of forms issued to compel an individual to appear for a deposition or to give testimony, or to produce documentation (Workers' compensation)
Employers First Report of Injury or Illness (LWC-WC IA-1)		155KB	LWC-WC IA-1 - (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. In turn, the insurance carrier, self-insured fund or self-insured employer is now obligated to enter the form as per instructions at http://lwcedi.info/
Disputed Claim for Compensation - Form 1008		75 KB	LWC-WC 1008 - Form to be filed with the Workers' Compensation district office when there is any disputed issue in a claim
Disputed Claim for Medical Treatment - Form 1009		23 KB	LWC-WC 1009 - Form to be filed with the Workers' Compensation Medical Services Director when there is a Disputed Claim for Medical Treatment.
Request of authorization/carrier or self insured employer response - Form 1010		354 KB	LWC-WC 1010 - Request of authorization/carrier or self insured employer response
Request of authorization/carrier or self insured employer response - Form 1010	Excel®	322 KB	LWC-WC 1010 - Request of authorization/carrier or self insured employer response
First request - Form 1010A		484KB	LWC-WC 1010A - First request
First request - Form 1010A	Excel®	252KB	LWC-WC 1010A - First request
Request for Compromise or Lump Sum Settlement		59 kb	LWC-WC 1011 - Form filed with OWCA to request the review and approval of a compromise or lump sum settlement agreement
Request for Independent Medical Exam - Form 1015		41 kb	LWC-WC 1015 - Form to be completed by party requesting an Independent Medical Examination (IME)
Quarterly Report of Injury/Illness	Web Application		LWC-WC 1017A - Quarterly Report of Injury/Illness
Glossary of Terms for Form 1017a		22 kb	LWC-WC 1017A - Glossary - Glossary of terms used when completing form LWC-WC 1017A
Employee's Monthly Report of Earnings - Form 1020		42 KB	LWC-WC 1020 - Form filed monthly with the employer’s insurer by the injured worker to report any earnings (Workers' compensation)
REPORTE MENSUAL DE GANANCIAS DEL EMPLEADO		78KB	LWC-WC 1020 (en Español) - REPORTE MENSUAL DE GANANCIAS DEL EMPLEADO
Cost Containment Application		154 KB	LWC-WC 1021 - Employer’s application for participation in the cost containment program (Workers' compensation)
CERTIFICADO DE CONFORMIDAD DEL TRABAJADOR		72KB	LWC-WC 1025 (en Español) - CERTIFICADO DE CONFORMIDAD DEL TRABAJADOR
Employee's Certificate of Compliance - Form 1025ee		57 KB	LWC-WC 1025.EE - Form filed by injured workers explaining rights and responsibilities while receiving workers’ compensation benefits and penalties for failure to comply
Employer's Certificate of Compliance - Form 1025er		14 KB	LWC-WC 1025.ER - Form filed by the employer explaining the employer’s rights and responsibilities to provide workers’ compensation benefits as well as penalties for failure to comply
Employee's Quarterly Report of Earnings - Form 1026		22 KB	LWC-WC 1026 - Form filed quarterly by the injured worker with their employer or insurer to report any earnings (Workers' compensation)
Request for Waiver of Payment of Advance Costs		113 KB	LWC-WC 1027 - Form used to determine whether the financial status of an injured worker warrants the waiver of payment of any advanced costs when filing claims (Workers' compensation)
Physician Choice Form		146 KB	LWC-WC 1121 - Form to be completed by the injured worker when selecting their physician of choice
ELEGIR A SU PROPIO DOCTOR New		45 KB	LWC-WC 1121 (en Español) - Formulario que completará el trabajador lesionado al seleccionar a su médico de elección
Workers Compensation Records Request Form		127 KB	LWC-WC 1150 - Form used to make a Workers Compensation Records Request
Employee Authorization for OWCA to Release Confidential Workers Compensation Records		118 KB	LWC-WC 1151 - OWCA form for Employee Authorization to Release Confidential Workers Compensation Records
Self-Insurer Application		57 kb	LWC-WC 2005 - Application form to be completed by employers wishing to become a self-insured entity (Workers' compensation)
Self-Insurer Application Checklist		84 kb	LWC-WC 2005 - Checklist - List of items necessary when submitting application to become self-insured (Workers' compensation)
Service Company Application		115 kb	LWC-WC 2007 - Application filed by companies requesting to operate as third party administrators in the state of Louisiana (Workers' compensation)
Service Company Application Checklist		22 KB	LWC-WC 2007 - Checklist - Checklist of items necessary when submitting an application in order to process workers’ compensation claims in Louisiana
Special Reimbursement Reconsideration Appeal Form		27 KB	LWC-WC 3000 - Form to be completed by medical provider when requesting reimbursement reconsideration appeal
OSHA Form 300 Instructions	Excel®		OSHA - 300 Log - OSHA 300, Log of Work-Related Injuries and Illnesses, Input Instructions Using Microsoft Excel).
Notice of Claim with Second Injury Fund		37 KB	SIB Form A - Form 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
P & I Form		157 kb	SIB Form B - Form submitted with each request for reimbursement from the Second Injury Board

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Fraud

Name	Format	Size	Description
Fraud Rules		10 KB	Title 40, Chapter 19 Rules. Outlines the guidelines required for compliance with the Workers' Compensation Act.
Warning Signs of Workers' Compensation Fraud		30 KB	Outlines signs of Workers' Compensation Fraud

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Medical Services

Name	Format	Size	Description
CPT Codes - 2000 Update		426 KB	Updated CPT for 2000
Rehabilitation Services		19 KB	Louisiana Maximum Fee Schedule, Chapter 7. Rehabilitation Services. Establishes guidelines for the rehabilitation of occupationally disabled employees
Special Reimbursement Reconsideration Appeal Form		27 KB	LWC-WC 3000 - Form to be completed by medical provider when requesting reimbursement reconsideration appeal
Utilization Review Contacts New		504 KB

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Records Management

Name	Format	Size	Description
An Overview of OWCA Section's Activity	HTML
OWC Employee Authorization Form		118 KB	OWC Employee Authorization Form
OWC Record Request Form		127 KB	OWC Record Request Form
OWCA Annual Reports Menu	HTML		This Workers' Compensation page provides annual statistics including reports and supplements.

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Second Injury Board

Name	Format	Size	Description
Electronic Funds Transfer Enrollment Form	HTML
Notice of Claim with Second Injury Fund		37 KB	SIB Form A - Form 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
P & I Form		157 kb	SIB Form B - Form submitted with each request for reimbursement from the Second Injury Board
Second Injury Board Knowledge Questionnaire		114 KB	Second Injury Board Knowledge Questionnaire
Second Injury Board Knowledge Questionnaire - Spanish		120 KB	Second Injury Board Knowledge Questionnaire - Spanish
Second Injury Board Meeting Schedule		9 KB	Meeting dates and deadlines for Second Injury Board meetings
Second Injury Board Mtg. Agenda New	HTML		Agenda for the Second Injury Board that meets the first Thursday of every month
Second Injury Fund		153 KB	Rules of Practice and Procedures
Second Injury Fund		26 KB	SIF Brochure - Brochure explaining the basic operation of the Second Injury Board
Settlement Evaluation		29 KB	Form 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		31 KB	Form submitted to the Second Injury Board for approval of a settlement on a claimant who has been declared permanently and totally disabled

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Workplace Safety

Name	Format	Size	Description
Directory of Safety Services		33 KB	Directory of Safety Services - Revised January 2012
Directory of Safety Services - Consultants - Applications		37 KB	Application for Directory of Safety Services
Quarterly Report of Injury/Illness	Web Application		LWC-WC 1017A - Quarterly Report of Injury/Illness
Safety Requirements		24 KB	Guidelines for implementing a working and occupational safety plan

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Miscellaneous

Name	Format	Size	Description
First request - Form 1010A		484KB	LWC-WC 1010A - First request
First request - Form 1010A	Excel®	252KB	LWC-WC 1010A - First request
Admitted Workers' Compensation Insurers		124 KB
Annual Report of Workers' Compensation Costs			LWC-WC 1000 - This Workers' Compensation page provides an annual report of Workers' Compensation costs.
Authorized Self-Insured Employers New		293 KB
Authorized Third Party Administrators		32 KB
Average Weekly Wage Computation		161 KB	Instructions for computing an employee’s average weekly wage (Workers' compensation)
CERTIFICADO DE CONFORMIDAD DEL TRABAJADOR		72KB	LWC-WC 1025 (en Español) - CERTIFICADO DE CONFORMIDAD DEL TRABAJADOR
Circuit Courts of Appeal		140 KB	Circuit Courts of Appeal
Cost Containment Application		154 KB	LWC-WC 1021 - Employer’s application for participation in the cost containment program (Workers' compensation)
Cost Containment Rules		25 KB	Guidelines to establish and implement effective injury control measures (Workers' compensation)
Derechos y Responsabilidades Para Los Empleados y Los Empleadores en La Compensación a Los Trabajadores New		89 KB	Rights And Responsibilities in Workers' Compensation (en Español)
Disputed Claim for Compensation - Form 1008		75 KB	LWC-WC 1008 - Form to be filed with the Workers' Compensation district office when there is any disputed issue in a claim
Disputed Claim for Medical Treatment - Form 1009		23 KB	LWC-WC 1009 - Form to be filed with the Workers' Compensation Medical Services Director when there is a Disputed Claim for Medical Treatment.
District Offices and Parishes Served		16 KB
Drug Testing Programs in Job Accident Cases		29 KB	Title 40. Chapter 15. Drug Testing Programs in Job Accident Cases. Guidelines for accident-related drug testing (Workers' compensation)
ELEGIR A SU PROPIO DOCTOR New		45 KB	LWC-WC 1121 (en Español) - Formulario que completará el trabajador lesionado al seleccionar a su médico de elección
Employee Authorization for OWCA to Release Confidential Workers Compensation Records		118 KB	LWC-WC 1151 - OWCA form for Employee Authorization to Release Confidential Workers Compensation Records
Employee's Certificate of Compliance - Form 1025ee		57 KB	LWC-WC 1025.EE - Form filed by injured workers explaining rights and responsibilities while receiving workers’ compensation benefits and penalties for failure to comply
Employee's Monthly Report of Earnings - Form 1020		42 KB	LWC-WC 1020 - Form filed monthly with the employer’s insurer by the injured worker to report any earnings (Workers' compensation)
Employee's Quarterly Report of Earnings - Form 1026		22 KB	LWC-WC 1026 - Form filed quarterly by the injured worker with their employer or insurer to report any earnings (Workers' compensation)
Employer's Certificate of Compliance - Form 1025er		14 KB	LWC-WC 1025.ER - Form filed by the employer explaining the employer’s rights and responsibilities to provide workers’ compensation benefits as well as penalties for failure to comply
Employers First Report of Injury or Illness (LWC-WC IA-1)		155KB	LWC-WC IA-1 - (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. In turn, the insurance carrier, self-insured fund or self-insured employer is now obligated to enter the form as per instructions at http://lwcedi.info/
Exempt Businesses		8 KB	Companies exempt from 300 log
Exemptions From Coverage		24 KB
Fiscal Responsibility		38 KB	Guidelines for employers and insurers providing workers’ compensation insurance coverage in Louisiana
FORM LWC-WC 1017 Exemptions by North American Industry Classification System (NAICS) Codes		8 KB
General Provisions		13 KB	Title 40. Chapter 1. General Provisions. Defines the responsibilities and rights of the employee, employer, and the carrier in the administration of workers' compensation in Louisiana.
Glossary of Terms for Form 1017a		22 kb	LWC-WC 1017A - Glossary - Glossary of terms used when completing form LWC-WC 1017A
Hearing Rules		751 KB	Office of Workers Compensation - Court Hearing Procedures (LAC 40:I.Chapters 55-66).
Interpreter/ADA Accommodations		53 KB	Form to request for a language interpreter or deaf/hearing impaired assistance in Workers’ Compensation Court
Letter of Credit		20 KB	Irrevocable Letter of Credit
Mileage Reimbursement		97 KB
Motion for Recognition of Right to Soc. Sec. Offset - Form 1005a		18 kb	LWC-WC 1005A - Form used by the employer/insurer to request recognition of right to take an offset for social security benefits (Workers' compensation)
Notice of Payment - Form 1002		165 KB	LWC-WC 1002 - Form to be completed by the Employer/Insurer and sent to the injured employee.
Order Recognizing Right to Soc. Sec. Offset - Form 1005b		19 kb	LWC-WC 1005B - Order signed by the workers’ compensation judge recognizing entitlement to a social security offset
OSHA Form 300 Instructions	Excel®		OSHA - 300 Log - OSHA 300, Log of Work-Related Injuries and Illnesses, Input Instructions Using Microsoft Excel).
OSHA Forms	Excel®	152 KB	OSHA Form 300, OSHA Form 300A, OSHA Form 301
OWC District Boundaries		16 KB	OWC District Boundaries
Parish Codes for Louisiana		6 KB	Listing of codes assigned to each parish
Physician Choice Form		146 KB	LWC-WC 1121 - Form to be completed by the injured worker when selecting their physician of choice
REPORTE MENSUAL DE GANANCIAS DEL EMPLEADO		78KB	LWC-WC 1020 (en Español) - REPORTE MENSUAL DE GANANCIAS DEL EMPLEADO
Request for Compromise or Lump Sum Settlement		59 kb	LWC-WC 1011 - Form filed with OWCA to request the review and approval of a compromise or lump sum settlement agreement
Request for Independent Medical Exam - Form 1015		41 kb	LWC-WC 1015 - Form to be completed by party requesting an Independent Medical Examination (IME)
Request for Social Security Benefits Information			LWC-WC 1004 - Form used to gather information from the Social Security Administration and to calculate the amount of any offset (Workers' compensation)
Request for Waiver of Payment of Advance Costs		113 KB	LWC-WC 1027 - Form used to determine whether the financial status of an injured worker warrants the waiver of payment of any advanced costs when filing claims (Workers' compensation)
Request of authorization/carrier or self insured employer response - Form 1010		354 KB	LWC-WC 1010 - Request of authorization/carrier or self insured employer response
Request of authorization/carrier or self insured employer response - Form 1010	Excel®	322 KB	LWC-WC 1010 - Request of authorization/carrier or self insured employer response
Rights and Responsibilities in Workers' Compensation New	HTML		Answers to the most frequently asked questions and concerns from employees and employers relating to Louisiana's workers' compensation entitlement and procedures.
Rights and Responsibilities in Workers' Compensation New		177 KB	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		37 KB	Documentation outlining conditions and containing required forms.
Self-Insurer Application		57 kb	LWC-WC 2005 - Application form to be completed by employers wishing to become a self-insured entity (Workers' compensation)
Self-Insurer Application Checklist		84 kb	LWC-WC 2005 - Checklist - List of items necessary when submitting application to become self-insured (Workers' compensation)
Service Company Application		115 kb	LWC-WC 2007 - Application filed by companies requesting to operate as third party administrators in the state of Louisiana (Workers' compensation)
Service Company Application Checklist		22 KB	LWC-WC 2007 - Checklist - Checklist of items necessary when submitting an application in order to process workers’ compensation claims in Louisiana
State of Louisiana Indemnity & Guaranty Agreement		20 KB	Legal document necessary to guarantee the self-insured’s obligation to pay indemnity benefits (Workers' compensation)
Stop Payment - Form 1003		54 KB	LWC-WC 1003 - Form is sent by the Employer/Insurer to the injured workers and OWCA.
Subpoena & Subpoena Duces Tecum - Form 1006		107KB	LWC-WC 1006 - Series of forms issued to compel an individual to appear for a deposition or to give testimony, or to produce documentation (Workers' compensation)
Surety Bond		8 KB	Legal document necessary when making application to become self-insured (Workers' compensation)
What is Workers' Compensation Fraud		87 KB	Defines Workers' Compensation Fraud
Workers Compensation Records Request Form		127 KB	LWC-WC 1150 - Form used to make a Workers Compensation Records Request

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Note: This revision date does not reflect the individual revision dates of the materials listed above, nor does it reflect the last time the listing was updated. Materials are updated on a regular basis and added to the list above as soon as they are made available.