Form Lwc Wc 1003 PDF Details

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.

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