Form Ldol-Wc 1020 - Workers' Compensation - Employee'S Monthly Report Of Earnings (Form Ldol-Wc-1020)
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1EMPLOYEE’S MONTHLY REPORT OF EARNINGS
You must submit this report to your employer’s workers’ compensation insurer within 30 days of your job-related injury, and every 30
days as long as you receive workers’ compensation indemnity benefits.
You do not have to submit this report if you have only
received medical benefits. Your workers’ compensation benefits may be suspended if you do not timely submit this report.
Warning: Per L.R.S. 23:1208 of the Louisiana Workers’ Compensation Statute, it shall be unlawful for a person, for the
purpose of obtaining or defeating any benefit payment under the provisions of this Chapter, either for himself or for any other
person, to willfully make a false statement or representation.
Penalties for violations include imprisonment, fines, and/or the
forfeiture of benefits.
DO NOT leave any blanks on this report.
Print or type all responses, and use Not Applicable (N/A) or Zero ( - 0-) where
appropriate.
1.
The information in this report is true for the period beginning _________________________, 20___ and ending
_____________________, 20 ____.
2.
For the period covered in this report, did you receive a salary, wage, sales commission, or payment, including cash, of any
kind?
Yes
No
If yes, give name and address of employer __________________________________________________________________
If yes, give your gross earnings___________________________________________________________________________
3.
For the period covered in this report, were you self-employed or involved in any business enterprise? These include but are
not limited to farming, sales work, operating a business (even if the business lost money), child care, yard work, mechanical
work, or any type of family business.
Yes
No
If yes, describe the type of business you are involved in, your job duties, and the amount of income received from the
business. ____________________________________________________________________________________________
____________________________________________________________________________________________________
4.
Did you perform any volunteer work during the period covered in this report?
Yes
No
If yes, describe the type of volunteer work you performed. _____________________________________________________
5.
Did you receive any unemployment insurance benefits for the period covered in this report?
Yes
No
If yes, how much? __________________ For how many weeks? ____________
6.
Did you receive any old age insurance benefits under Title II of the Social Security Act?
_ Yes
No
If yes, how much? ___________________
7.
Did you receive any Social Security Disability Benefits, retirement benefits, or any other type of disability or government
benefits?
Yes
No
If yes, how much? _______________ What type of benefits did you receive? ___________________________________
Employee Certification
I certify that I understand the contents of this entire document and 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.
________________________________________________
________________________________________________
Print Name
Signature
Social Security Number
Date
________________________________________________
_____(_________)___________________________________
Physical/Street Address
City
State/Zip
Telephone Number
________________________________________________
____________________________(______)______________
Date of Injury
Claim Number
Insurer
Telephone Number
LDOL-WC 1020
REVISED 07/01/2001
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