Non-Compliance Employer's Reporting Form

If you suspect an employer doing business in Louisiana of not carrying the necessary workers' compensation insurance please complete the requested information below. Please click the Submit button at the bottom of the form when all the necessary information has been entered.

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(*) Entry Required

1. * Name of the business you are reporting.
   
2. Name of the owner of the business.
   
3. Address, city, state, and telephone number of the business.
   
   Character Count: (Max 200, remaining 200.)
   
4. Parish of the business.
   
5. Federal ID of the business.
   
6. Job site address, city, state, and telephone number (If different from business address).
   
   Character Count: (Max 200, remaining 200.)
   
7. Parish of the job site.
   
8. Type of business.
   
9. * Alleged Violation (Select all that apply):
    No Worker's Compensation Coverage
    Business Underreporting Payroll
    Business Misclassifying Employees
    Other (Please explain)
   
10. Description of alleged violation.
    
    Character Count: (Max 200, remaining 200.)
11. Does the business currently have workers' compensation insurance?
    
12. If yes, current workers' compensation insurance carrier.
    
13. How many employees does this employer have?
    
14. Have there been any job related injuries within the past 60 days?
    
15. Name of employee involved.
    
16. Date of injury.
    
17. If you wish to be contacted by this office, please give us your name, address, telephone number, and/or email address.
    
    Character Count: (Max 200, remaining 200.)
    
    E-Mail:
18. Any additional information you would like to submit.
    
    Character Count: (Max 200, remaining 200.)

If you have any other questions, please email WCFraud@lwc.la.gov
or call toll-free 1-800-201-3362.