Form Lwc-Wc-1000 - Annual Report Of Workers' Compensation Costs Page 2
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1
2Paid by Employer
Paid by Insurance
E. TOTAL FUNERAL EXPENSES
F. Legal Expenses
1. Attorney Fees
2. Court Costs
3. Deposition Costs
4. Investigation Costs
5. Penalties and Interest
6. Administrative/Other Costs
TOTAL LEGAL EXPENSES
G. Cost Summary
1. Total Indemnity Benefits (ITEM A)
2. Total Compromise/Lump Sum Settlements (ITEM
B)
3. Total Medical Expenses (ITEM C)
4. Total Rehabilitation Costs (ITEM D)
5. Total Funeral Expenses (ITEM E)
6. 3rd Party Recoveries for Costs (not included
above)
7. Total Assessable Costs (1+2+3+4+5-6)
8. Total Legal Expenses (ITEM F)
9. TOTAL WORKERS' COMPENSATION COSTS
H. Number of Claims Summary
1. Carried over from prior year
2. Opened during current year
3. Closed during current year
4. Open at year end ( 1 + 2 - 3)
5. Total Medical only claims
I. OPEN RESERVE CLAIMS
(at year end)
Number
Amount
NOTE: The amount of compensation benefits paid will be used by the Director to make assessments for the administration of the
Workers' Compensation Office under the provisions of Act 29, 1983, R.S. 23:1291.1 All other information submitted will be used for
statistical records only with the names of employers and carriers being confidential and privileged. (LA R.S. 23:1293)
FOR OFFICIAL USE ONLY
I certify that the information contained herein is true
and correct to the best of my knowledge and belief.
_________________________________________
Signature
Date
R E T U R N T O :
A T T N : A U D I T & C O M P L I A N C E
O F F I C E O F W O R K E R S ' C O M P E N S A T I O N
P . O B O X 9 4 0 4 0
B A T O N R O U G E , L A 7 0 8 0 4 - 9 0 4 0
LWC-WC-1000
( 2 2 5 ) 3 4 2 - 5 6 5 8 ( P H O N E ) ( 2 2 5 ) 3 4 2 - 7 5 7 8 ( F A X )
REV. 01/10
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