Lwc-Wc-1026 - Employee'S Quarterly Report Of Earnings printable pdf download

Lwc-Wc-1026 - Employee'S Quarterly Report Of Earnings

EMPLOYEE'S QUARTERLY REPORT OF EARNINGS

You must submit this Report to your workers' compensation insurer within 14 days. Your workers' compensation benefits may

be suspended if you do not timely submit this Report. You would be entitled to all suspended benefits after this report is provided

to your Insurer, if you are otherwise eligible for benefits.

You do not have to file this report if you have timely filed all necessary LWC-WC-1020 forms, or if you have only received

medical benefits.

DO NOT leave any blanks on this Report. Print or type all responses, and use N/A (not applicable) or -0- (zero) where

appropriate.

The information in this Report is true for the period beginning

, 20

and ending

, 20

The name and address of the employer that I am receiving benefits from is:

Did you work for this employer in the past quarter?

If yes, how much were your gross wages? $

Did you work for any other employer in the past quarter?

If yes, the name and address of

the employer is

If yes, how much were your gross wages? $

Did you have any earnings through self employment in the past quarter?

If yes, how much? $

Did you receive any unemployment compensation benefits in the past quarter?

If yes, how much? $

I received $

in old age benefits under Title ll of the Social Security Act.

I received $

in Social Security Disability Benefits or other disability benefits.

EMPLOYEE CERTIFICATION

I certify that I can read the English language, that I have this entire document and understand its contents, and that I understand

I am held responsible for this information. I certify my answers are complete and true, and certify my compliance with the

Louisiana Workers' Compensation Act.

SIGNATURE

SOCIAL SECURITY NUMBER

PRINT NAME

ADDRESS

CITY

STATE / ZIP

PHONE NUMBER

EMPLOYER NAME

DATE

LWC-WC-1026

REVISED 7/08

Lwc-Wc-1026 - Employee'S Quarterly Report Of Earnings