Form Ldol-Wc-1008 - Disputed Claim For Compensation Form - Office Of Workers' Compensation
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1
2-
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1.
.
Mail To:
Social Security No
LOCAL DISTRICT OFFICE
-
-
2.
Date of Injury/Illness
OR
OFFICE OF WORKERS' COMPENSATION
POST OFFICE BOX 94040
3.
Part(s) of Body Injured
BATON ROUGE, LA 70804-9040
4.
Date of This Request
-
-
For information call (225) 342-7565
or Toll Free (800) 201-3457.
5.
Date of Hire
-
-
6.
Date of Birth
-
-
Docket Number
DISPUTED CLAIM FOR COMPENSATION
7. This claim is submitted by:
__ Employee
__ Employer
__ Insurer
__ Dependent
__ Health Care Provider
__ LDOL
__ Other
GENERAL INFORMATION
Claimant files this dispute with the Office of Workers' Compensation. This office must be notified immediately in writing of changes
in address. An employee may be represented by an attorney, but it is not required.
EMPLOYEE
EMPLOYEE'S ATTORNEY
8.
Name
9. Name
Street or Box
Street or Box
City
City
State
Zip
State
Zip
Phone (
)
Phone (
)
EMPLOYER
INSURER/ADMINISTRATOR
(circle one)
10. Name
11. Name
Attn:
Attn:
Street or Box
Street or Box
City
City
State
Zip
State
Zip
Phone (
)
Phone (
)
EMPLOYER/INSURER'S ATTORNEY
DEPENDENT/HCP/OTHER
(circle one)
(circle one)
12. Name
13. Name
Attn:
Relationship
Street or Box
Street or Box
City
City
State
Zip
State
Zip
Phone (
)
Phone (
)
14. EMPLOYMENT DATA
Occupation:
Average Weekly Wage $
Workers' Compensation Rate $
LDOL-WC-1008
REV. 1/98
COMPLETE BOTH PAGES
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