Form Ldol-Wc-1007 - Employer Report Of Injury/illness - Louisiana Workforce Commission
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1MAIL TO:
-
-
WORKERS' COMPENSATION INSURER
Employee Social Security Number
Employer UI Account Number
EMPLOYER REPORT
Employer Federal ID Number
OF
INJURY/ILLNESS
This report is completed by the Employer for each injury/illness identified by them or their employee as occupational. A copy
is to be provided to the employee and the insurer immediately.
PURPOSE OF REPORT: (Check all that apply)
__ More than 7 days of disability
__ Possible dispute
__ Medical only
__ Injury resulted in death
__ Lump Sum Compromise/Settlement
( DO NOT mail copy to OWCA )
__ Amputation or disfigurement
__ Other
1.Date ofReport
2. Date / time of Injury
3. Normal Starting Time Day
4. If Back toWork -
5. At same wage?
DO NOT WRITE
MM/DD/YY
MM/DD/YY Time
of Accident
Give date
__Yes __ No
IN THIS
__AM
__ AM
MM/DD/YY
COLUMN
__PM
__ PM
6. If Fatal Injury, Give Date of
7. Date Employer Knew of
8. Date Disability
9. Last Full Day Paid
Date Received
Death MM/DD/YY
Injury MM/DD/YY
began MM/DD/YY
MM/DD/YY
10. Employee Name First
Middle
Last
11. __ Male
12. Employee Phone #
Naics:.
__ Female
(
)
13. Address and Zip Code
14. Parish of Injury
State-Parish
15. Date of Hire
16. Date of Birth
17. Occupation
18. Dept/Division Employed
Occupation
19. Place of Injury-Employer's
20. If No, Indicate Location-Street, City, Parish and State
Nature
Premises ?
__ Yes __ No
21. What work activity was the employee doing when the injury occurred? (Give weight, size and shape of materials or equipment involved). Explain what
Part of Body
employee was doing with them. Indicate if correct procedures were followed.
Source
Event
NCCI
22. What caused injury to happen? (Describe fully the events which resulted in injury or disease. Explain what happened and how it happened. Name any objects or substances involved and explain how they were
involved. Give full details on all factors which led to or contributed to this injury or illness.)
23. Part of Body Injured and Nature of Injury or Illness (ex. left leg; multiple fractures)
24. If Occ. Disease-Give Date
Diagnosed
25. Physician and Address
26. If Hospitalized, give name & address of facility
27. Employer's Name
28. Person Completing This Report - Please print
29. Employer's Address and Zip Code
30. Employer's Telephone Number
(
)
31. Employer's Mailing Address-If Different From Above
32. Nature of Business-Type of Mfg., Trade, Construction, Service, etc.
Wage Information (optional)
Employee was paid __ Daily
__ Weekly
__ Monthly
__ Other.
T he average weekly wage was $
per week.
33.
LDO
L-WC-1007 Insurer Name:
Insurer's Administrator or Representative:
Rev: 08/06
Phone:
Phone:
Address:
Address:
Download Employer’s Certificate of Compliance
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