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.
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 |
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 |
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 |
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. |
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 |
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 |
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 |
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.