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Workers' Compensation

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Forms - Numerical

Name Format Size Description
Annual Report of Workers' Compensation Costs This document is a PDF. LWC-WC 1000 - This Workers' Compensation page provides an annual report of Workers' Compensation costs.
Notice of Payment - Form 1002 New This document is a PDF. 165 KB LWC-WC 1002 - Form to be completed by the Employer/Insurer and sent to the injured employee.
Stop Payment - Form 1003 This document is a PDF. 54 KB LWC-WC 1003 - Form is sent by the Employer/Insurer to the injured workers and OWCA.
Request for Social Security Benefits Information This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 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)
Disputed Claim for Compensation - Form 1008 This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 340 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® 326KB LWC-WC 1010 - Request of authorization/carrier or self insured employer response
First request - Form 1010A This document is a PDF. 484KB LWC-WC 1010A - First request
First request - Form 1010A Excel® 252KB LWC-WC 1010A - First request
Request for Compromise or Lump Sum Settlement This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 22 kb LWC-WC 1017A - Glossary - Glossary of terms used when completing form LWC-WC 1017A
Employee's Monthly Report of Earnings - Form 1020 This document is a PDF. 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 This document is a PDF. 78KB LWC-WC 1020 (en Español) - REPORTE MENSUAL DE GANANCIAS DEL EMPLEADO
Cost Containment Application This document is a PDF. 154 KB LWC-WC 1021 - Employer’s application for participation in the cost containment program (Workers' compensation)
CERTIFICADO DE CONFORMIDAD DEL TRABAJADOR This document is a PDF. 72KB LWC-WC 1025 (en Español) - CERTIFICADO DE CONFORMIDAD DEL TRABAJADOR
Employee's Certificate of Compliance - Form 1025ee This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 146 KB LWC-WC 1121 - Form to be completed by the injured worker when selecting their physician of choice
Self-Insurer Application This document is a PDF. 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 This document is a PDF. 84 kb LWC-WC 2005 - Checklist - List of items necessary when submitting application to become self-insured (Workers' compensation)
Service Company Application This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 27 KB LWC-WC 3000 - Form to be completed by medical provider when requesting reimbursement reconsideration appeal
Employers First Report of Injury or Illness (LWC-WC IA-1) New This document is a PDF. 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/
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 This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 10 KB Title 40, Chapter 19 Rules. Outlines the guidelines required for compliance with the Workers' Compensation Act.
Warning Signs of Workers' Compensation Fraud This document is a PDF. 30 KB Outlines signs of Workers' Compensation Fraud
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Medical Services

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

Name Format Size Description
1999 OWCA Annual Report Supplement This document is a PDF. 44 KB
2000 OWCA Annual Report Supplement This document is a PDF. 46 KB
2001 OWCA Annual Report This document is a PDF. 239 KB
2001 OWCA Annual Report Supplement This document is a PDF. 42 KB
2002 OWCA Annual Report This document is a PDF. 237 MB
2002 OWCA Annual Report Supplement This document is a PDF. 424 KB
2003 OWCA Annual Report This document is a PDF. 206 MB
2003 OWCA Annual Report Supplement This document is a PDF. 223 KB
2004 OWCA Annual Report This document is a PDF. 239 KB
2005 OWCA Annual Report This document is a PDF. 428 KB
2006 OWCA Annual Report This document is a PDF. 452KB
2007 OWCA Annual Report This document is a PDF. 947 KB
2008 OWCA Annual Report This document is a PDF. 278 KB
2009 OWCA Annual Report This document is a PDF. 418 KB
2009 OWCA Annual Report Supplement This document is a PDF. 56 KB
2010 OWCA Annual Report This document is a PDF. 427 KB
2011 OWCA Annual Report This document is a PDF. 534 KB
2012 OWCA Annual Report This document is a PDF. 730 KB
2013 OWCA Annual Report New This document is a PDF. 790 KB
An Overview of OWCA Section's Activity HTML
Body Parts Diagram This document is a PDF. 63 KB
OWCA Annual Reports Menu This document is a PDF. 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 This document is a PDF.
Notice of Claim with Second Injury Fund This document is a PDF. 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 This document is a PDF. 157 kb SIB Form B - Form submitted with each request for reimbursement from the Second Injury Board
Second Injury Board Knowledge Questionaire This document is a PDF. 138 KB Second Injury Board Knowledge Questionaire
Second Injury Board Knowledge Questionaire - Spanish This document is a PDF. 128 KB Second Injury Board Knowledge Questionnaire - Spanish
Second Injury Board Meeting Schedule New This document is a PDF. 12 KB Meeting dates and deadlines for Second Injury Board meetings
Second Injury Board Mtg. Agenda This document is a PDF. 153 KB Agenda for the Second Injury Board that meets the first Thursday of every month
Second Injury Fund This document is a PDF. 153 KB SIF Brochure - Rules of Practice and Procedures
Second Injury Fund This document is a PDF. 26 KB SIF Brochure - Brochure explaining the basic operation of the Second Injury Board
Settlement Evaluation This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 33 KB Directory of Safety Services - Revised January 2012
Directory of Safety Services - Consultants - Applications This document is a PDF. 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 This document is a PDF. 24 KB Guidelines for implementing a working and occupational safety plan
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Miscellaneous

Name Format Size Description
First request - Form 1010A This document is a PDF. 484KB LWC-WC 1010A - First request
First request - Form 1010A Excel® 252KB LWC-WC 1010A - First request
Admitted Workers' Compensation Insurers This document is a PDF. 124 KB
Annual Report of Workers' Compensation Costs This document is a PDF. LWC-WC 1000 - This Workers' Compensation page provides an annual report of Workers' Compensation costs.
Authorized Group Self-Insurance Company Listing This document is a PDF. 23 KB
Authorized Third Party Administrators This document is a PDF. 32 KB
Average Weekly Wage Computation This document is a PDF. 88 KB Instructions for computing an employee’s average weekly wage (Workers' compensation)
CERTIFICADO DE CONFORMIDAD DEL TRABAJADOR This document is a PDF. 72KB LWC-WC 1025 (en Español) - CERTIFICADO DE CONFORMIDAD DEL TRABAJADOR
Circuit Courts of Appeal This document is a PDF. 140 KB Circuit Courts of Appeal
Cost Containment Application This document is a PDF. 154 KB LWC-WC 1021 - Employer’s application for participation in the cost containment program (Workers' compensation)
Cost Containment Rules This document is a PDF. 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 This document is a PDF. 89 KB Rights And Responsibilities in Workers' Compensation (en Español)
Disputed Claim for Compensation - Form 1008 This document is a PDF. 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 This document is a PDF. 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.
Drug Testing Programs in Job Accident Cases This document is a PDF. 29 KB Title 40. Chapter 15. Drug Testing Programs in Job Accident Cases. Guidelines for accident-related drug testing (Workers' compensation)
Employee's Certificate of Compliance - Form 1025ee This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 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) New This document is a PDF. 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 This document is a PDF. 8 KB Companies exempt from 300 log
Exemptions From Coverage This document is a PDF. 24 KB
Fiscal Responsibility This document is a PDF. 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 This document is a PDF. 8 KB
General Provisions This document is a PDF. 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 This document is a PDF. 22 kb LWC-WC 1017A - Glossary - Glossary of terms used when completing form LWC-WC 1017A
Hearing Offices Contact Information This document is a PDF. 20 KB
Hearing Rules This document is a PDF. 348 KB Office of Workers Compensation - Court Hearing Procedures (LAC 40:I.Chapters 55-66).
How's Business? Windows® Media® 8.4 MB WAFB Channel 9 Interview with Sonny Mills 4/27/2005
Interpreter/ADA Accommodations New This document is a PDF. 53 KB Form to request for a language interpreter or deaf/hearing impaired assistance in Workers’ Compensation Court
Letter of Credit This document is a PDF. 20 KB Irrevocable Letter of Credit
Motion for Recognition of Right to Soc. Sec. Offset - Form 1005a This document is a PDF. 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 New This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 16 KB OWC District Boundaries
Parish Codes for Louisiana This document is a PDF. 6 KB Listing of codes assigned to each parish
Physician Choice Form This document is a PDF. 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 This document is a PDF. 78KB LWC-WC 1020 (en Español) - REPORTE MENSUAL DE GANANCIAS DEL EMPLEADO
Request for Compromise or Lump Sum Settlement This document is a PDF. 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 This document is a PDF. 41 kb LWC-WC 1015 - Form to be completed by party requesting an Independent Medical Examination (IME)
Request for Social Security Benefits Information This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 340 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® 326KB 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 This document is a PDF. 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 New This document is a PDF. 37 KB Documentation outlining conditions and containing required forms.
Self-Insurer Application This document is a PDF. 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 This document is a PDF. 84 kb LWC-WC 2005 - Checklist - List of items necessary when submitting application to become self-insured (Workers' compensation)
Service Company Application This document is a PDF. 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 This document is a PDF. 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 This document is a PDF. 20 KB Legal document necessary to guarantee the self-insured’s obligation to pay indemnity benefits (Workers' compensation)
Stop Payment - Form 1003 This document is a PDF. 54 KB LWC-WC 1003 - Form is sent by the Employer/Insurer to the injured workers and OWCA.
Subpoena & Subpoena Duces Tecum - Form 1006 This document is a PDF. 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 This document is a PDF. 8 KB Legal document necessary when making application to become self-insured (Workers' compensation)
What is Workers' Compensation Fraud This document is a PDF. 87 KB Defines Workers' Compensation Fraud
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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.