Fillable Printable Disputed Claim for Compensation - Louisiana

Disputed Claim for Compensation - Louisiana

LWC-WC-1008

REV. 4/14

COMPLETE BOTH PAGES

Mail To:

Social Security No. - -

LOCAL DISTRICT OFFICE

2. Date of Injury/Illness

- -

OFFICE OF WORKERS' COMPENSATION

POST OFFICE BOX 94040

3. Part(s) of Body Injured

BATON ROUGE, LA 70804-9040

For information call (225) 342-7565

4. Date of This Request

- -

or Toll Free (800) 201-3457.

5. Date of Hire

- -

6. Date of Birth - -

Docket Number

DISPUTED CLAIM FOR COMPENSATION

7. This claim is submitted by:

__ Employee __ Employer __ Insurer __ Dependent __ Health Care Provider __ LWC __ Other

GENERAL INFORMATION

Claimant files this dispute with the Office of Workers' Compensation. This office must be notified immediately in writing of changes

in address. An employee may be represented by an attorney, but it is not required.

EMPLOYEE EMPLOYEE'S ATTORNEY

8. Name

9. Name

Street or Box

City City

State

Zip State Zip

Phone ( ) Phone ( )

EMPLOYER INSURER/ADMINISTRATOR

(circle one)

10. Name

11. Name

Attn: Attn:

Street or Box Street or Box

City City

State Zip State Zip

Phone ( ) Phone ( )

EMPLOYER/INSURER'S ATTORNEY

(circle one)

DEPENDENT/HCP/OTHER

(circle one)

12. Name

13. Name

Attn: Relationship

Street or Box Street or Box

City City

State Zip State Zip

Phone ( ) Phone ( )

14. EMPLOYMENT DATA

Occupation:

Average Weekly Wage $ Workers' Compensation Rate $

LWC-WC-1008

REV. 4/14

COMPLETE BOTH PAGES

15. TO BE COMPLETED BY INJURED EMPLOYEE OR DEPENDENT:

(A) ACCIDENT DATA

Date, time and place of accident:

Parish of Residence at time of Injury/Illness

Accident reported on / / , to whose position with the employer is

Describe the accident and injury in detail (person/equipment involved, type of injury, etc.)

List the names, addresses, telephone numbers of any witnesses.

(B) MEDICAL DATA

State the names, addresses, and telephone numbers of hospitals, clinics and doctors who have provided medical attention.

Check the following that apply and fill in the blanks:

__ 1. No wage benefits have been paid

__ 2. No medical treatment has been authorized

__ 3. Occupational Disease

__ 4.

Workers' Compensation Rate is Incorrect - Should be $

__ 5. Wage benefits terminated or reduced on / /

__ 6. Medical treatment (Procedure/Prescription)

recommended by not authorized.

__ 7. Choice of physician (specialty)

__ 8. Disability status

__ 9. Vocational Rehabilitation - specify

__ 10. Offset/Credit

__ 11. Refusal to authorize/submit to evaluation with choice of physician/Independent Medical Examination [L. R. S. 23:1121, 1124(B), or 1317.1(F)]

__ 12. Other:

NOTE: You may attach a letter or petition with additional information with this disputed claim or

when later amending this disputed claim (Form LWC-WC-1008). You must provide a

copy of this claim and any amendment to all opposing parties.

The information given above is true and correct to the best of my knowledge and belief.

SIGNATURE OF CLAIMANT/ATTORNEY DATE

(circle one)