Annual Report Of Workers' Compensation Costs

This form is semi-interactive and may be filled out online.

Form LWC-WC-1000 should be completed by all self-insured employers, insurance companies, and group self-insureds paying benefits which satisfy an employer's obligation to pay workers' compensation benefits in the state of Louisiana.  Information gathered will be used as the basis to assess companies to cover the cost of administration of the Office of Workers' Compensation.  The completed form must be submitted to the office by April 30th.  This information is requested pursuant to L.R.S. 23:1291.1.

1. EMPLOYER INFORMATION:
   
   Provide complete information.  If the form is pre-printed and contains incorrect information, draw a line through the incorrect information and write in the correct information. Be sure to include the name of the individual completing the form and your Federal Employer Identification Number (FEIN).
   
   
2. INSURANCE COMPANY INFORMATION:
   
   
   • Employers:
     
     Provide complete information for the insurance company that carries your standard workers' compensation insurance policy or your excess insurance policy (if self-insured), or your other policies which in the aggregate satisfy your workers' compensation obligation. You should also provide the name of the individual representative that you contact regarding your insurance. Please provide the insurance company's NCCI identifying number if you can obtain it.
     
     
   • Insurers:
     
     Provide complete information on your company.
     
     
3. COVERAGE PROVIDED:
   
   
   • Employers:
     
     Indicate the method of providing workers' compensation coverage by checking the appropriate box.
     
     

     NOTE: If you are an employer and all of your benefits are paid by insurance, do not fill in the cost information requested. Sign and date the form on the bottom of page 2, and return it to the Office of Workers' Compensation.

   • Insurers:
     
     Check each box for the types of coverage your company provides.
     
     
4. COST INCURRED DURING THE CALENDAR YEAR:
   
   Please provide the cost incurred in fulfilling your workers' compensation obligation in such detail as the form requires.
   
   

   NOTE: Credits are now allowed for benefits recovered by reimbursement from third parties (i.e. Second Injury Fund or subrogation, etc.) but not from Excess Insurance. See Section G item 6.

   "Paid by Employer" generally refers to claims paid by the employer (or its agent) when the employer is self-insured.
   
   
   • A-E.
     INDEMNITY, LUMP SUM SETTLEMENTS, MEDICAL, REHABILITATION, AND FUNERAL EXPENSES: Provide detail for each different category of benefits paid during the year.  "Penalties & Interest" refers to those items assessed against the employer and required to be paid to the injured worker as part of his/her wage indemnity benefits. 
     
     
   • F.
     LEGAL COSTS: Please provide the detail requested.
     "Administrative Costs" include such things as copies, travel, telephone charges, etc.
     
     
   • G.
     COST SUMMARY: Fill in the total dollars of benefits and costs as determined from 4A -4F, and total those amounts. Total assessable cost is the sum of benefits paid for indemnity, lump-sum settlements, medical care, rehabilitation, and funeral expenses. Third party recoveries should not have been deducted from the totals in Sections 4A-4E. Deduct recoveries in Section G, line 6
     
     
   • H.
     NUMBER OF CLAIMS SUMMARY: Lines 1 - 4 are a summary of claims processed during the calendar year.  The number of claims carried over from the prior year plus the number of claims opened during the current calendar year minus claims closed during the year of this report must equal the number of claims open at year's end.  Also, please include on line 5 the number of claims for medical expenses only.
     
     
   • I.
     OPEN RESERVE CLAIMS: Indicate the number of claims for which a reserve exists and the total dollar amount of that reserve.
     
     

If you need assistance in filling out this form, please contact the Office of Workers' Compensation at (225) 342-5658 or 342-7571 or by sending an email to wcaudit@lwc.la.gov.

NOTE: L.R.S. 23:1291.1 provides that an insurer or employer may be penalized for failure to submit the Annual Report by April 30th.  The penalty is a percentage of the amount of the assessment on a properly completed form and is calculated at 10% per month, or fraction thereof, through June 30th and 20% per month, or fraction thereof, after June 30th.

Download Form 1000 (PDF) (LWC-WC-1000 Rev. January 2010)
(This form is semi-interactive and may be filled out online.)