Cost Containment Meeting Application {WC-1021}

Kathleen Babineaux Blanco Governor John Warner Smith Secretary OFFICE OF WORKERS' COMPENSATION ADMINISTRATION LOUISIANA WORKFORCE COMMISSION OSHA CONSULTATION COST CONTAINMENT MEETING APPLICATION IN ORDER TO QUALIFY FOR PARTICIPATION IN THE COST CONTAINMENT PROGRAM. THE EXPERIENCE MODIFIER RATE FOR YOUR COMPANY MUST HAVE BEEN 1.50 OR HIGHER AS OF DECEMBER 31 OF THE PRIOR YEAR. THIS INFORMATION CAN BE OBTAINED FROM YOUR WORKERS' COMPENSATION INSURANCE CARRIER OR SELF-INSURED ASSOCIATION. Date: __________________________ Company Name: _______________________________________________ Mailing Address: _______________________________________________ City, State and Zip: _____________________________________________ Telephone: ________________ Fax: ______________________________ Experience Modifier Rate: ____________ as of December 31 of the prior year Name and Title of Representative: _________________________________________________________________ (please print or type) Representative Signature: __________________________________________________________________________________ Date and location of meeting applying for: ____________________________________________________________________ _______________________________________________________________________________________________________ Louisiana Workforce Commission OSHA Consultation P. O. Box 94094 Baton Rouge, LA 70804-9094 (225) 342-9601 or 800-201-2495 Fax: (225) 342-5158 LWC-OWC #1021 (REVISED 01/09) Workplace Safety and Health - 1001 North 23rd Street - Post Office Box 94040 - Baton Rouge, LA 70804-9040 phone 225-342-9601 or 800-201-2495 - fax 225-342-5158 - www.LAWORKS.net Equal Opportunity Employer/Program Auxiliary aids and services are available upon request to individuals with disabilities American LegalNet, Inc. www.FormsWorkflow.com