Form Ldol-Wc-1003 - Stop Payment Form
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1MAIL TO:
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OFFICE OF WORKER'S COMPENSATION
SOCIAL SECURITY NUMBER
POST OFFICE BOX 94040
BATON ROUGE, LA 70807-9040
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(225) 342-7565, TOLL FREE (800) 201-3457
DATE OF INJURY/ILLNESS
STOP PAYMENT FORM
This form is sent by the Employer/Insurer to the injured worker and the OWC within 30 days of the closure of a case.
An AMENDED COPY is required if the case re-opens or additional costs are incurred.
1.
2.
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(Employee)
(Date of Birth)
Date of this Notice
3.
4.
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Part(s) of Body Injured
Date Compensation Paid Through
5.
Purpose of Form: (check one)
‘ Payment stopped-Employee working at equal or greater wage
‘ Payment stopped-Maximum period for paying SEB has expired
‘ Payment stopped-Employee able to work at same or greater wage
‘ Payment stopped-3rd Party recovery without notice
‘ Payment stopped-Lump sum/Compromise settlement approved
‘ Amend or correct prior 1003
‘ Other
6.
Length of Disability
weeks
days.
7.
Give ICD - 9 Diagnostic code(s)
.
8.
Give CPT Procedure code(s)
.
9.
COSTS INCURRED FOR THIS CASE:
A. Indemnity Benefits
1. Temporary total ....................... $
D. Rehabilitaiion Expenses
2. Supplemental earnings ..............
1. Medical rehabilitation .....................$
3. Permanent partial .....................
2. Vocational rehabilitation ...................
4. Permanent total ........................
3. Labor Market Survey .......................
5. Death benefits ...........................
4. Evaluation.........................................
6. Other benefits ..........................
5. Other ................................................
TOTAL INDEMNITY BENEFITS......
TOTAL REHABILITATION EPENSES........
(Add A. items 1-6)
(Add D. Items 1-5)
B. TOTAL SETTLEMENT AMOUNT $
C. Medical Expenses
E. TOTAL FUNERAL EXPENSES..........$
1. Hospital ..................................$
2. Physician ..................................
F. Legal Expenses
3. Diagnostic Tests/Procedures....
1. Attorney Fees ...............................$
4. Prescription Drugs.....................
2. Court Costs ...................................
5. Transportation Costs..................
3. Deposition Costs ..........................
6. Independent Medical Exams.....
4. Investigation Costs........................
7. Occupational/Physical Therapy.
5. Penalties and Interest ...................
8. Other.............................................
6. Administrative/Other Costs............
TOTAL MEDICAL EXPENSES............
TOTAL LEGAL EXPENSES .......................
(Add C. Items 1-8)
(Add E. Items 1-5)
G. 3RD PARTY RECOVERIES FOR COSTS ..........$
(NOT INCLUDED ABOVE)
H.
TOTAL WORKERS' COMPENSATION COSTS $
(Add A - G)
I .
BALANCE OF UNUSED RESERVES..................$
Submitted by:
Preparer's Name:
Employer/Insurer:
Address:
Phone: (
)
Empoyer/Insurer NCCI Number:
LDOL-WC-1003
REV. 1/98
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