Get LA LWC-WC-1007 1998-2021
10/98 LUBA-WC-1007 32. Nature of Business Type of Mfg. Trade Construction Service etc. 31. Employers Mailing Address If Different From Above Daily Weekly NAME OF WORKERS COMPENSATION INSURER PHONE NUMBER 225 389-5822 Monthly The average weekly wage was per week. MAIL TO - WORKERS COMPENSATION INSURER Employee Social Security Number Employer UI Account Number EMPLOYER REPORT OF INJURY/ILLNESS Employer Federal ID Number 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 OWCA. PURPOSE OF REPORT Check all that apply More than 7 days of disability Injury resulted in death Amputation or disfigurement 1. Date of Report MM/DD/YY 2. Date / Time of injury 6. If Fatal injury give Date of Death MM/DD/YY Possible dispute Lump Sum Compromise/Settlement Other Time AM PM 3. Normal Starting Time Day of Accident 7. Date Employer Knew of Injury MM/DD/YY 10. Employee Name First Middle 4. If Back to Work Give date 5. At same wage yes DO NOT WRITE IN THIS COLUMN no 8. Date Disability Began MM/DD/YY Last Medical only DO NOT mail copy to OWCA Male Female 9. Last Full Day Paid Date Received 12. Employee Phone S*I. C 14. Parish of Injury State-Parish 18. Dept/Division Employed 13 Address and Zip Code Occupation LA 15. Date of Hire 16. Date of Birth 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 incident occurred Give weight size and shape of materials or equipment Involved* Tell what he was doing with them* Indicate if correct procedures were followed* Part of Body Source Event NCCI 22. What caused incident to happen Describe fully the events which resulted in injury or disease. Tell what happened and how it happened* Name any objects or substances involved and tell 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 33. Wage Information optional Employee was paid LDOL-WC-1007 REV. MAIL TO - WORKERS COMPENSATION INSURER Employee Social Security Number Employer UI Account Number EMPLOYER REPORT OF INJURY/ILLNESS Employer Federal ID Number 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 OWCA. .
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