Louisiana > Workers Comp
Employer Report Of Injury Or Illness WC-1007 - Louisiana
| Employer Report Of Injury Or Illness Form. This is a Louisiana form and can be used in Workers Comp . |
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MAIL TO: OFFICE OF WORKERS' COMPENSATION POST OFFICE BOX 94040 BATON ROUGE, LA. 70804-9040 (225) 342-7565 TOLL FREE (800) 201-3457 Employee Social Security Number Employer UI Account Number EMPLOYER REPORT Employer Federal ID Number OF INJURY/ILLNESS This report is completed by the Employer for each injury/illness identified by them or their employee as occupational. A copy is to be provided to the employee and the insurer immediately. Forms for cases resulting in more than 7 days of disability or death are to be sent to the OWCA by the 10th day after the injury or as requested by the OWCA. PURPOSE OF REPORT: (Check all that apply.) _ More than 7 days of disability _ Possible dispute _ Medical only รบรบรบ _ Injury resulted in death _ Lump Sum Compromise/Settlement ( DO NOT mail copy to OWCA. ) _ Amputation or disfigurement _ Other 2. Date / time of Injury MM/DD/YY Time _AM _PM 3. Normal Starting Time Day of Accident _ AM _ PM 4. If Back toWork Give date MM/DD/YY 5. At same wage? _Yes _ No DO NOT WRITE IN THIS COLUMN 1.Date ofReport MM/DD/YY 6. If Fatal Injury, Give Date of Death MM/DD/YY 7. Date Employer Knew of Injury MM/DD/YY 8. Date Disability began MM/DD/YY 9. Last Full Day Paid MM/DD/YY Date Received 10. Employee Name First Middle Last 11. _ Male _ Female 12. Employee Phone # ( ) 14. Parish of Injury S.I.C. 13. Address and Zip Code State-Parish 15. Date of Hire 16. Date of Birth 17. Occupation 18. Dept/Division Employed Occupation 19. Place of Injury-Employer's Premises ? _ Yes _ No 20. If No, indicate location - Street, City, Parish and State Nature 21. What work activity was the employee doing when the injury occurred? (Give weight, size and shape of materials or equipment involved). Explain what employee was doing with them. Indicate if correct procedures were followed. Part of Body Source Event NCCI 22. What caused injury to happen? (Describe fully the events which resulted in injury or disease. Explain what happened and how it happened. Name any objects or substances involved and explain how they were involved. Give full details on all factors which led to or contributed to this injury or illness.) 23. Part of Body Injured and Nature of Injury or Illness (ex. left leg; multiple fractures) 24. If Occ. Disease-Give Date Diagnosed 25. Physician and Address 26. If Hospitalized, give name & address of facility 27. Employer's Name 28. Person Completing This Report - Please print 29. Employer's Address and Zip Code 30. Employer's Telephone Number ( ) 31. Employer's Mailing Address-If Different From Above 32. Nature of Business-Type of Mfg., Trade, Construction, Service, etc. 33. Wage Information (optional) Employee was paid _ Daily _ Weekly _ Monthly _ Other. T he average weekly wage was $ per week. LDOL-WC-1007 NAME OF WORKERS' COMPENSATION INSURER: REV. 10/98 PHONE NUMBER ( ) American LegalNet, Inc. www.USCourtForms.com American LegalNet, Inc. www.USCourtForms.com
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