Form Lwc-Wc-1000 - Annual Report Of Workers' Compensation Costs

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ANNUAL REPORT OF WORKERS' COMPENSATION COSTS
FOR CALENDAR YEAR _____________
1. EMPLOYER INFORMATION
INSURANCE COMPANY INFORMATION
2.
Account #
Account #
Name:
Name:
Address:
Address:
City, St., Zip:
City, St. Zip:
Contact Person:
Contact Person:
Phone #:
Phone #:
Fed EIN:
Phone Number:
(
)
3. Coverage Provided:
Self-insured / Excess Insurance
Conventional Workers' Compensation Policy
Combination of Insurance Policies [R.S. 23:1168(A)(2)]
4. COSTS INCURRED DURING THE CALENDAR YEAR (See Instructions)
Paid by Employer
Paid by Insurance
A. Indemnity Benefits:
1. Temporary Total
2. Supplemental Earnings
3. Permanent Partial
4. Permanent Total
5. Death Benefits
6. Other Compensation
TOTAL INDEMNITY BENEFITS
B. TOTAL COMPROMISE/LUMP SUM SETTLEMENTS:
C. Medical Expenses:
1. Hospital
2. Physicians
3. Diagnostic Tests/Procedures
4. Prescription Drugs
5. Transportation
6. Independent Medical Exams
7. Physical/Occupational Therapy
8. Other
TOTAL MEDICAL EXPENSES
D. Rehabilitation Expenses
1. Vocational Rehabilitation
2. Labor Market Surveys
3. Evaluations
4. Other
TOTAL REHABILITATION EXPENSES
LWC-WC-1000
REV. 01/10

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