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Notice Of Payment

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MAIL TO:

Social Security No

OFFICE OF WORKERS' COMPENSATION

POST OFFICE BOX 94040

2. Date of Injury/Illness

BATON ROUGE, LA 70804-9040

(225) 342-7565

TOLL FREE (800) 201-3457

NOTICE OF PAYMENT

This form is to be completed by the Employer/Insurer and sent to the injured employee with the first

check or within 10 days of suspension/modification and/or change to SEB. A copy must be sent to the

Office of Workers' Compensation Administration within 10 days of the effective date.

Purpose of Form (check one):

Payment

Modification

Suspension

Change to SEB

Employee Name

Effective Date

Part(s) of Body Injured

Nature of Injury

Compensation is paid as follows:

Weekly payments of $

based on an average weekly wage of $

have

begun.

Payments re-started at $

per week.

Payments reduced by $

due to:

__ Social Security Benefits

__ Other Workers' Compensation Benefits

__ Employer Disability Benefits

__ Unemployment Insurance Benefits

__ Third Party Recovery

__ Refused Rehabilitation

__ Other:

Permanent Partial Benefits of $

will be paid for

weeks.

Supplemental Earnings Benefits of $

will begin

The exact amount received weekly may vary.

Death Benefits have begun in the amount of $

per week,

representing

% of wages.

Payment suspended due to employee failing to cooperate.

Other reasons or explanations

Submitted by:

Preparer's Name:

Employee Name:

Employer/Insurer:

Employer:

Address:

(

)

____

(

)

Phone:

Phone :

Employer/Insurer NCCI Number:

LDOL-WC-1002

REV. 10/98

Notice Of Payment

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