Form Lwc-Wc-1007 - Employer Report Of Injury/illness
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1MAIL TO:
LOUISIANA WORKERS’ COMPENSATION COVERAGE
Fire Department Name
Employee Social Security Number
2237 S. ACADIAN THRUWAY
72-0724657
SUITE 102
Fire Department ID Number (FDID)
Employer Federal ID Number
BATON ROUGE, LA 70808
134893
/
225-924-7788
Insurance Policy No.
Claim Number
EMPLOYER REPORT
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
th
sent to the OWCA by the 10
day after the incident or as requested by the OWCA.
PURPOSE OF REPORT: (Check all that apply)
More than 7 days of disability
Possible dispute
Medical only
Injury resulted in death
Lump Sum Compromise/Settlement
(DO NOT mail copy OWCA)
Amputation or disfigurement
Other
1.Date of Report
2.Date/time of Injury
3.Normal Starting Time
4. If Back to Work, Give date
5.At same wage?
DO NOT WRITE
MM/DD/YYYY
MM/DD/YYYY Time
Day of Accident
MM/DD/YYYY
__ Yes
IN THIS
_ AM
_ AM
COLUMN
__ No
_ PM
_ PM
6.If Fatal Injury, Give Date of Death
7.Date Employer Knew of Injury
8.Date Disability Began
9.Last Full Day Paid
Date Received
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
10.Employee Name: First
Middle
Last
11. __ Male
12.Employee Phone #
Naics:
(
)
__ Female
13.Address and Zip Code:
14.Parish of Injury
State-Parish
15.Date of Hire
16.Date of Birth
17.Occupation
18.Dept/Division Employed
Occupation
MM/DD/YYYY
MM/DD/YYYY
19.Place of Injury Employer’s
20.If No, Indicate Location-Street, City, Parish and State
Nature
Premises?
__ Yes
__ No
21.What work activity was the employee doing when the injury occurred? (Give weight, size and shape of materials or equipment
Part of body
involved). Explain what employee was doing with them. Indicate if correct procedures were followed.
Source
Event
NCCI
22.What caused injury to happen? (Describe fully the events which resulted in injury or disease. Explain what happened and ho w 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
MM/DD/YYYY
25.Physician Name 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
The average weekly wage was $ ____________ per wk
LWC-
Insurer Name:
Insurer’s Administrator or Representative:
WC-1007
Rev: 07/08
Phone:
(
)
Phone:
(
)
Address:
Address:
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