Form Lwc-Wc-1003 - Stop Payment Form

Download a blank fillable Form Lwc-Wc-1003 - Stop Payment Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Lwc-Wc-1003 - Stop Payment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

MAIL TO:
__________-__________-__________
OFFICE OF WORKERS’ COMPENSATION
SOCIAL SECURITY NUMBER
POST OFFICE BOX 94040
BATON ROUGE, LA 70804-9094
(225) 342-7565, TOLL FREE (800) 201-3457
___________________________
DATE OF INJURY/ILLNESS
STOP PAYMENT FORM
This form is sent by the Employer/Insurer to the injured workers and the OWCA within 30 days of the closure of a case.
An AMENDED COPY is required if the case re-opens or additional costs are incurred.
____________________________________________
2.
__________-__________-__________
1.
(Employee)
(Date of Birth)
Date of this Notice
3.
____________________________________________
4.
__________-__________-__________
Part(s) of Body Injured
Date Compensation Paid Through
Purpose of Form: (check one)
1.
_ Payment stopped-Employee working at equal or greater wages
_ Payment stopped-Maximum period for paying SEB has expired
_ Payment stopped-Employee able to work at same or greater wages
_ Payment stopped-3rd Party recovery without notice
_ Payment stopped-Lump sum/Compromise settlement approved
_ Amend or correct prior 1003
_ Other___________________________________________
6.
Length of Disability__________weeks__________days.
Give ICD - 9 Diagnostic code(s)________________________________
7.
Give CPT Procedure code(s)__________________________________
8.
__________________________________________________________________________________________________________________________
9.
COSTS INCURRED FOR THIS CASE:
A.
Indemnity Benefits
D. Rehabilitation Expenses
1. Temporary total
_________________
1. Medical Rehabilitation
_________________
2. Supplemental earnings
_________________
2. Vocational Rehabilitation
_________________
3. Permanent partial
_________________
3. Labor Market Survey
_________________
4. Permanent total
_________________
4. Evaluation
_________________
5. Death Benefits
_________________
5. Other
_________________
6. Other Benefits
_________________
$0.00
$0.00
TOTAL INDEMNITY BENEFITS
$________________
TOTAL REHABILITATION EXPENSES
$________________
(Add A. Items 1-6)
(Add D. Items 1-5)
B.
TOTAL SETTLEMENT AMOUNT
$________________
E. TOTAL FUNERAL EXPENSES
$________________
C.
Medical Expenses
F. Legal Expenses
1. Hospital
_________________
1. Attorney Fees
_________________
2. Physician
_________________
2. Court Costs
_________________
3. Diagnostic Tests/Procedures
_________________
3. Deposition Costs
_________________
4. Prescription Drugs
_________________
4. Investigative Costs
_________________
5. Transportation Costs
_________________
5. Penalties and Interest
_________________
6. Independent Medical Exams
_________________
6. Administrative/Other Costs
_________________
7. Occupational/Physical Therapy
_________________
8. Other
_________________
0.00
0.00
TOTAL MEDICAL EXPENSES
$________________
TOTAL LEGAL EXPENSES
$________________
(Add C. Items 1-8)
(Add F. Items 1-6)
RD
G. 3
PARTY RECOVERY FOR COSTS
$________________
(Not Included Above)
0.00
H. TOTAL WORKERS’ COMPENSATION COSTS
$________________
(Add A-G)
I.
BALANCE OF UNUSED RESERVES
$________________
Submitted by:
Preparer’s Name: ________________________________
Employee Name: __________________________________
Employer/Insurer: ________________________________
Employer: ________________________________________
Address: _______________________________________
Address: _________________________________________
_______________________________________________
_________________________________________________
Phone: (
) ___________________________________
Phone: (
) _____________________________________
Employer/Insurer NCCI Number:_____________________
LWC-WC-1003
REV. 07/08

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go