Louisiana > Workers Comp
Request For Compromises Or Lump Sum Settlement WC-1011 - Louisiana
| Request For Compromises Or Lump Sum Settlement Form. This is a Louisiana form and can be used in Workers Comp . |
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RETURN TO: OFFICE OF WORKERS' COMPENSATION POST OFFICE BOX 94040 BATON ROUGE, LA 70804-9040 (225) 342-7565 TOLL FREE (800) 201-3457 1. 2. 3. 4. 5. Social Security No. Date of Injury/Illness Part(s) of Body Injured OWC Docket Number OWC District Number - - REQUEST FOR COMPROMISE OR LUMP SUM SETTLEMENT DATE OF APPROVAL JUDGE EMPLOYEE 6. Name Street or Box City State Phone Zip 7. Name Street or Box City State Phone EMPLOYEE'S ATTORNEY Zip EMPLOYER 8. Name Street or Box City State Phone Zip 9. Name Street or Box City State Phone INSURER/ADMINISTRATOR (circle one) Zip EMPLOYER/INSURER'S ATTORNEY (circle one) 10. Name Street or Box City State Phone 11. DATE OF SETTLEMENT CONFERENCE 12. TERMS AND AMOUNT OF SETTLEMENT: 13. BENEFITS PAID TO DATE: a.) AVERAGE WEEKLY WAGE: b.) WORKERS' COMPENSATION BENEFITS: c.) MEDICAL BENEFITS: d.) DEATH BENEFITS: 14. ATTORNEY FEES PAID TO DATE: 15. ADDITIONAL FEES REQUIRED: Zip ATTACHMENTS REQUIRED: JOINT PETITION FORM 1007 ATTACHED OR ON FILE FORM 1003 ATTACHED OR ON FILE EMPLOYEE AFFIDAVIT EMPLOYER CONCURRENCE ALLEGATION OF LEGAL REPRESENTATION MOST RECENT MEDICAL REPORT WAIVER OF RIGHTS UNDER L.R.S. 23:1271 FILING FEE PAID ORDER OF APPROVAL MOTION AND ORDER FOR ATTORNEY FEES MOTION AND ORDER TO DISMISS 1008 (IF APPLICABLE) SUBMITTED BY: PHONE: LWC-WC-1011 REV. 07/08 American LegalNet, Inc. www.FormsWorkFlow.com
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