Form Ldol-Wc-1011 - Request For Compromise Or Lump Sum Settlement - 1998
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1RETURN TO:
1.
Social Security No.
-
-
OFFICE OF WORKERS' COMPENSATION
2.
Date of Injury/Illness
-
-
POST OFFICE BOX 94040
3.
Part(s) of Body Injured
4.
OWC Docket Number
BATON ROUGE, LA 70804-9040
(225) 342-7565
5.
OWC District Number
TOLL FREE (800) 201-3457
REQUEST FOR COMPROMISE
OR LUMP SUM SETTLEMENT
DATE OF APPROVAL
JUDGE
EMPLOYEE
EMPLOYEE'S ATTORNEY
6. Name
7.
Name
Street or Box
Street or Box
City
City
State
Zip
State
Zip
Phone (
)
Phone (
)
EMPLOYER
INSURER/ADMINISTRATOR
(circle one)
8. Name
9. Name
Street or Box
Street or Box
City
City
State
Zip
State
Zip
Phone (
)
Phone (
)
EMPLOYER/INSURER'S ATTORNEY
(circle one)
10. Name
Street or Box
City
State
Zip
Phone (
)
11. DATE OF SETTLEMENT CONFERENCE
12. TERMS AND AMOUNT OF SETTLEMENT:
13. BENEFITS PAID TO DATE:
a.) AVERAGE WEEKLY WAGE:
b.) WORKERS' COMPENSATION BENEFITS:
c.) MEDICAL BENEFITS:
d.) DEATH BENEFITS:
14. ATTORNEY FEES PAID TO DATE:
15. ADDITIONAL FEES REQUIRED:
ATTACHMENTS REQUIRED
:
MOST RECENT MEDICAL REPORT
JOINT PETITION
WAIVER OF RIGHTS UNDER L.R.S. 23:1271
FORM 1007 ATTACHED
OR ON FILE
FORM 1003 ATTACHED
OR ON FILE
FILING FEE PAID
EMPLOYEE AFFIDAVIT
ORDER OF APPROVAL
EMPLOYER CONCURRENCE
MOTION AND ORDER FOR ATTORNEY FEES
ALLEGATION OF LEGAL REPRESENTATION
MOTION AND ORDER TO DISMISS 1008
(IF APPLICABLE)
SUBMITTED BY:
PHONE: (
)
LDOL-WC-1011
REV. 1/98
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