Form Ldol-Wc-1025.er - Employer Certificate Of Compliance
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1EMPLOYER CERTIFICATE OF COMPLIANCE
You must submit this Certification to your workers' compensation insurer. Failure to submit this Certification as
required may result in your being penalized by a fine of $500, payable to your insurer.
You must secure workers' compensation for your employees through insurance or by becoming an authorized self-
insured. If you fail to provide security for workers' compensation, you must pay an additional 50% in weekly benefits to your
injured workers.
If you willfully fail to provide security for workers' compensation, then you are subject to a fine of up to $10,000,
imprisonment with or without hard labor for not more than 1 year, or both. If you have been previously fined and again fail
to provide security for workers' compensation, then you are subject to additional penalties, including a court order to cease
and desist from continuing further business operations.
You must not collect, demand, request, or accept any amount from any employee to pay or reimburse for the
workers' compensation insurance premium. If you violate this provision, you may be punished with a fine of not more than
$500, or imprisoned with or without hard labor for not more than one year, or both.
It is unlawful for you to willfully make, or to assist or counsel someone else to make, a false statement or
representation in order to obtain or to defeat workers' compensation benefits. If you violate this provision, you may be fined
up to $10,000, imprisoned with or without hard labor for up to 10 years, or both depending on the amount of benefits
unlawfully obtained or defeated. In addition to these criminal penalties, you may be assessed a civil penalty of up to $5,000.
EMPLOYER CERTIFICATION
I certify that I have read this entire document and understand its contents, and that I understand I am held
responsible for this information. I certify my compliance with the Louisiana Workers' Compensation Act.
Preparer Name
(PRINT)
Signature
Date
Company Name
Company Address
(
)
Phone Number
Insurance Policy Number
-
-
Employee Name
Employee Social Security Number
LDOL-WC-1025.ER
REV. 1/02
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Parent category: Business