Form Lwc Wc 1003 PDF Details

In the realm of workers' compensation, the intricacies of navigating post-injury procedures can be daunting for both employers and employees alike. The LWC WC 1003 Stop Payment form serves as a critical document in this process, ensuring that all parties are duly informed when an employer or insurer decides to terminate compensation payments to an injured worker. This form, mandated for use by the Office of Workers' Compensation in Baton Rouge, Louisiana, encapsulates a range of essential details, from the basics such as the worker's social security number and the injury date, to the specifics like the parts of the body injured and the compensation paid through date. Employers or insurers are required to furnish this document within 30 days of case closure, and an amended copy is necessary if the case re-opens or additional costs are incurred. The form also delineates the reasons for stopping payments—be it because the employee has returned to work at equal or greater wages, the maximum period for SEB payments has expired, a lump sum or compromise settlement has been approved, among other reasons. Beyond the cessation of payments, the form delves into the length of disability, diagnostic and procedure codes, incurred costs including indemnity benefits, rehabilitation expenses, medical expenses, and even funeral expenses when applicable, culminating in a comprehensive summary of the total workers’ compensation costs and the balance of unused reserves. This detailed framework not only ensures compliance with Louisiana's workers' compensation laws but also provides a structured means for tracking and managing the financial aspects of a worker's injury claim.

QuestionAnswer
Form NameForm Lwc Wc 1003
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesOWCA, Insurer, NCCI, LWC-WC-1003

Form Preview Example

 

MAIL TO:

 

 

 

OFFICE OF WORKERS’ COMPENSATION

 

 

__________-__________-__________

 

POST OFFICE BOX 94040

 

 

SOCIAL SECURITY NUMBER

 

BATON ROUGE, LA 70804-9094

 

 

 

(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 workers and the OWCA 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.

__________-__________-__________

 

(Employee)

(Date of Birth)

 

Date of this Notice

3.

____________________________________________

4.

__________-__________-__________

 

Part(s) of Body Injured

 

 

Date Compensation Paid Through

1.Purpose of Form: (check one)

_ Payment stopped-Employee working at equal or greater wages

_

Payment stopped-Maximum period for paying SEB has expired

_

Payment stopped-Employee able to work at same or greater wages

_

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

D.

Rehabilitation Expenses

 

1.

Temporary total

_________________

1.

Medical Rehabilitation

_________________

2.

Supplemental earnings

_________________

2.

Vocational Rehabilitation

_________________

3.

Permanent partial

_________________

3.

Labor Market Survey

_________________

4.

Permanent total

_________________

4.

Evaluation

_________________

5.

Death Benefits

_________________

5.

Other

_________________

6.

Other Benefits

_________________

 

 

 

TOTAL INDEMNITY BENEFITS

$________________

TOTAL REHABILITATION EXPENSES

$________________

 

(Add A. Items 1-6)

 

(Add D. Items 1-5)

 

B.

TOTAL SETTLEMENT AMOUNT

$________________

E. TOTAL FUNERAL EXPENSES

$________________

C.

Medical Expenses

 

F. Legal Expenses

 

 

1.

Hospital

_________________

1.

Attorney Fees

_________________

 

2.

Physician

_________________

2.

Court Costs

_________________

 

3.

Diagnostic Tests/Procedures

_________________

3.

Deposition Costs

_________________

 

4.

Prescription Drugs

_________________

4.

Investigative Costs

_________________

 

5.

Transportation Costs

_________________

5.

Penalties and Interest

_________________

 

6.

Independent Medical Exams

_________________

6.

Administrative/Other Costs

_________________

 

7.

Occupational/Physical Therapy

_________________

 

 

 

 

8.

Other

_________________

 

 

 

TOTAL MEDICAL EXPENSES

$________________

TOTAL LEGAL EXPENSES

$________________

(Add C. Items 1-8)

 

 

(Add F. Items 1-6)

 

 

 

G.

3RD PARTY RECOVERY FOR COSTS

$________________

 

 

 

(Not Included Above)

 

 

 

 

 

H. TOTAL WORKERS’ COMPENSATION COSTS

$________________

 

 

 

(Add A-G)

 

 

 

 

I.

BALANCE OF UNUSED RESERVES

 

$________________

Submitted by:

 

 

 

 

 

 

Preparer’s Name: ________________________________

Employee Name: __________________________________

Employer/Insurer: ________________________________

Employer: ________________________________________

Address: _______________________________________

Address: _________________________________________

_______________________________________________

_________________________________________________

Phone: (

) ___________________________________

Phone: (

) _____________________________________

Employer/Insurer NCCI Number:_____________________

LWC-WC-1003

REV. 07/08