Form Lwc Wc 1003 is a document that is used to provide notice to the LLC’s members of certain events or decisions that have been made by the LLC. It is also used to provide information on the financial condition of the company. This form must be filed with the state whenever an event or decision listed in it occurs. Events that may require filing this form include changes in ownership percentages, termination of a member, or the sale or transfer of all or substantially all of the LLC’s assets. This form can be important for LLC members as it provides information on the company’s financial status and any recent changes. By staying informed of these events, members can make better decisions about their role in the company and their investment in it.
Question | Answer |
---|---|
Form Name | Form Lwc Wc 1003 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | OWCA, Insurer, NCCI, LWC-WC-1003 |
|
MAIL TO: |
|
|
|
OFFICE OF WORKERS’ COMPENSATION |
|
|
||
|
POST OFFICE BOX 94040 |
|
|
SOCIAL SECURITY NUMBER |
|
BATON ROUGE, LA |
|
|
|
(225) |
|
|
___________________________ |
|
|
|
|
|
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 |
|||
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 |
_ |
Payment |
|
_ |
Payment |
_ |
Payment |
_ |
Payment |
_ 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 |
|
(Add D. Items |
|
||
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 |
|
|
(Add F. Items |
|
||
|
|
G. |
3RD PARTY RECOVERY FOR COSTS |
$________________ |
||
|
|
|
(Not Included Above) |
|
|
|
|
|
H. TOTAL WORKERS’ COMPENSATION COSTS |
$________________ |
|||
|
|
|
(Add |
|
|
|
|
|
I. |
BALANCE OF UNUSED RESERVES |
|
$________________ |
|
Submitted by: |
|
|
|
|
|
|
Preparer’s Name: ________________________________ |
Employee Name: __________________________________ |
|||||
Employer/Insurer: ________________________________ |
Employer: ________________________________________ |
|||||
Address: _______________________________________ |
Address: _________________________________________ |
|||||
_______________________________________________ |
_________________________________________________ |
|||||
Phone: ( |
) ___________________________________ |
Phone: ( |
) _____________________________________ |
Employer/Insurer NCCI Number:_____________________
REV. 07/08