Louisiana > Workers Comp

Notice Of Payment Modification Suspension Termination Or Controversion Of Compensation Of Medical Benefits WC-1002 - Louisiana

Notice Of Payment Modification Suspension Termination Or Controversion Of Compensation Of Medical Benefits Form. This is a Louisiana form and can be used in Workers Comp .
 Fillable pdf Last Modified 7/27/2015
Get this form for FREE as a print-only pdf

EMPLOYER/PAYOR MAIL TO: OFFICE OF WORKERS' COMPENSATION POST OFFICE BOX 94040 BATON ROUGE, LA 70804-9040 1. Employee Social Security No. ______ -_____-_______ 2. Payor Claim No.:______________________________ 3. Date of Injury/Illness ___________________________ 4. Date of Notice: ________________________________ NOTICE OF PAYMENT, MODIFICATION, SUSPENSION, TERMINATION OR CONTROVERSION OF COMPENSATION OR MEDICAL BENEFITS 5. Purpose of Form (check one): Initial Payment ____ 6. (a) Modification ____ Suspension ____ Termination____ Controversion ____ Employee Name: ____________________________________________________ Address: ____________________________________________________ Telephone: __________________________________________________ Employee Representative Name (if known)_________________________________ Address: ____________________________________________________ ____________________________________________________ Telephone: ___________________________________________________ Facsimile: ____________________________________________________ Employer Name: ____________________________________________________ Address: ____________________________________________________ _____________________________________________________ Telephone: ___________________________________________________ Facsimile: ____________________________________________________ (b) (c) 7. Effective Date of Initial Payment, Modification, Suspension, Termination or Controversion:______/______/20_____ 8. Description of Injury/Occupational Disease: ________________________________________________________ ______________________________________________________________________________________________ 9. Average Weekly Wage: $__________________ 10. Payment/Modification (check one): Initial Payment ____ Indemnity Benefits are to be paid as follows: A. Permanent Total Disability (PTD)___ Temporary Total Disability (TTD)___ (check one) benefits at the rate of $_____________ per week; Supplemental Earnings Benefits (SEB) paid at the rate of $__________________per ________________ based on a wage earning capacity of $________________________; OR SEB paid at the rate of$ _______________ per ________________ dependent on wages as reflected in LWCWC-1020's to be submitted by employee each month; C. Reduced PTD___ TTD____ SEB_____ (check one) at the rate of $___________ due to employee's receipt of (check applicable item): _____ Social Security Benefits at the rate of $______________ per _____________; _____ Other Workers' Compensation Benefits at the rate of $__________ per _________' _____ Employer Funded Disability Benefits at the rate of $___________ per __________; _____ Unemployment Insurance Benefits _____ Third Party Recovery in the amount of $_______________ _____ 50% reduction of compensation based on Employee's refusal to cooperate with Vocational Rehabilitation _____ Reduction due to child support order _____ Other (Describe): _________________________________________________________ Modification____ B. American LegalNet, Inc. www.FormsWorkFlow.com D. Permanent Partial Disability (PPD) Benefits of $______________ per week payable for ____________ weeks. E. Death Benefits have begun in the amount of $ _________ per week, representing ______% of AWW. Employee Name __________________ Date of injury/illness________________ 11. Suspension/Termination Indemnity and/or Medical Benefits have been suspended/terminated due to: _____ Employee's refusal to submit to a medical examination; _____ Employee's refusal to execute a Choice of Physician form; _____ Fraud _____ Dispute over Compensability (Describe): ______________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _____ Employee's refusal to return the form LWC-WC-1025 or LWC-WC-1020; _____ Released to return to work full duty; _____ Employee able to earn 90% of pre-accident average weekly wage; or _____ Other (Describe): ________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 12. Controversion Employee's rights to Indemnity and/or Medical Benefits are disputed and have been denied because Employer/Payor disputes: _____ Compensable Work Accident; _____ Compensable Injury; _____ Employment Relationship; _____ Causation; _____ Disability; _____ Fraud; _____ Jurisdiction; or _____ Other (Describe): _________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 13. Notice Submitted By: Signature of Preparer: ______________________________________________ Printed name: _____________________________________________________ Position/Affiliation: _______________________________________________ Telephone:________________________________________________________ Facsimile: ________________________________________________________ Address: _________________________________________________________ ________________________________________________________ 14. Please provide the following information: Payor/Self Insured Employer Name: ___________________________________ Telephone ________________________________________________________ Facsimile: ________________________________________________________ Address: _________________________________________________________ _________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com NOTICE OF DISAGREEMENT (to be completed by Employee/Employee Representative) MAIL TO: The preparer for Employer/Payor at the address listed in Section 13 of the LWC-WC-1002. Employee Social Security No.: _______-____-________ Payor Claim No. (if known): ______________________ Date of Injury/Illness: ___________________________ Date of Notice of Disagreement: ___________________ BASIS OF DISAGREEMENT 1. 2. Average Weekly Wage is incorrect. The correct AWW amount is $______________. The type of workers' compensation
Link/Embed this Document

Popular Searches

  1. proof of claim
  2. divorce forms
  3. abstract of judgment
  4. form interrogatories
  5. Affidavit of Indigency
  6. MOTION for continuance
  8. order of protection
  9. quit claim deed
  10. Case Management Statement

Bookmark and Share