Form Lwc Wc 1008 PDF Details

The LWC WC 1008 form serves as a critical component in the process of disputing claims within the scope of workers' compensation in Louisiana. Aimed at addressing disagreements between parties involving matters such as wage benefits, medical treatment authorization, and the accuracy of workers' compensation rates, this form presents a structured method for individuals to communicate their grievances to the Louisiana Workforce Commission's Office of Workers' Compensation. Parties who may submit this dispute include, but are not limited to, employees, employers, insurers, dependents, and healthcare providers. The submission process requires detailed information about the claimant, the employer, the insurer or administrator, and any legal representatives involved. It also prompts the reporting of specific accident and medical data, alongside outlining the nature of the bona fide dispute. The form emphasizes the necessity for the claimant to notify the office promptly of any address changes and provides an avenue for both represented and self-represented claimants to argue their case. With sections dedicated to employment data, accident description, medical treatment records, and dispute specifics, the LWC WC 1008 form encapsulates the complexity of workers' compensation disputes while striving to ensure that each case is reviewed thoroughly and judiciously.

QuestionAnswer
Form NameForm Lwc Wc 1008
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameslwc 1008 form, DISPUTED, Claimant, 1008 form

Form Preview Example

Mail To:

1.

Social Security No.

 

-

 

-

 

 

LOCAL DISTRICT OFFICE

OR

OFFICE OF WORKERS' COMPENSATION POST OFFICE BOX 94040

BATON ROUGE, LA 70804-9040 For information call (225) 342-7565

or Toll Free (800) 201-3457.

Docket Number

2.

Date of Injury/Illness

 

-

 

-

3.Part(s) of Body Injured

4.

Date of This Request

-

-

 

 

 

5.

Date of Hire

 

 

-

 

 

 

 

 

-

 

 

 

 

 

 

 

6.

Date of Birth

 

 

-

 

 

 

-

 

 

 

 

 

DISPUTED CLAIM FOR COMPENSATION

7. This claim is submitted by:

 

 

 

 

__ Employee

__ Employer

__ Insurer

__ Dependent

__ Health Care Provider

__ LWC __ Other

GENERAL INFORMATION

Claimant files this dispute with the Office of Workers' Compensation. This office must be notified immediately in writing of changes in address. An employee may be represented by an attorney, but it is not required.

 

 

 

 

EMPLOYEE

 

 

 

 

 

 

 

 

 

EMPLOYEE'S ATTORNEY

 

 

8. Name

 

 

 

 

9. Name

 

 

 

 

 

 

 

 

Street or Box

 

 

 

 

Street or Box

 

 

 

City

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

Zip

 

 

State

 

 

 

 

Zip

 

 

 

Phone ( )

 

 

 

 

Phone (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER

 

 

 

 

 

 

 

 

 

INSURER/ADMINISTRATOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(circle one)

 

 

 

10. Name

 

 

 

 

 

 

 

 

11. Name

 

 

 

 

 

 

 

 

 

Attn:

 

 

 

 

 

 

 

 

Attn:

 

 

 

 

 

 

 

 

 

Street or Box

 

 

Street or Box

 

 

 

City

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

 

 

 

Zip

 

 

 

State

 

 

 

 

Zip

 

 

 

 

Phone (

)

 

 

 

 

 

Phone (

)

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER/INSURER'S ATTORNEY

 

 

 

 

 

 

DEPENDENT/HCP/OTHER

 

 

 

 

 

 

 

(circle one)

 

 

 

 

 

 

(circle one)

 

 

12. Name

 

 

 

 

 

 

13. Name

 

 

 

 

 

 

 

Attn:

 

 

 

 

 

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street or Box

 

 

 

 

 

Street or Box

 

 

 

 

 

 

City

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

Zip

 

 

State

 

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone (

)

 

 

 

 

Phone (

)

 

 

 

 

 

14.EMPLOYMENT DATA

Occupation:

Average Weekly Wage $

 

Workers' Compensation Rate $

LWC-WC-1008

REV. 4/14

COMPLETE BOTH PAGES

15.TO BE COMPLETED BY INJURED EMPLOYEE OR DEPENDENT:

(A)ACCIDENT DATA

Date, time and place of accident:

Parish of Residence at time of Injury/Illness

Accident reported on

 

/

/

, to

 

whose position with the employer is

Describe the accident and injury in detail (person/equipment involved, type of injury, etc.)

List the names, addresses, telephone numbers of any witnesses.

(B)MEDICAL DATA

State the names, addresses, and telephone numbers of hospitals, clinics and doctors who have provided medical attention.

(C)THE BONA-FIDE DISPUTE

Check the following that apply and fill in the blanks:

 

 

 

 

 

 

 

 

 

 

__

1.

No wage benefits have been paid

 

 

 

 

 

 

 

 

 

 

__

2.

No medical treatment has been authorized

 

 

 

 

 

 

 

 

 

 

__

3.

Occupational Disease

 

 

 

 

 

 

 

 

 

 

__

4.

Workers' Compensation Rate is Incorrect - Should be $

 

 

 

 

 

 

 

 

 

__

5.

Wage benefits terminated or reduced on

 

/

/

 

 

 

 

 

 

 

 

__

6.

Medical treatment (Procedure/Prescription)

 

 

 

 

 

 

 

 

 

 

 

 

recommended by

 

 

 

 

not authorized.

__

7.

Choice of physician (specialty)

 

 

 

 

 

 

 

 

 

 

 

__

8.

Disability status

 

 

 

 

 

 

 

 

 

 

 

__

9.

Vocational Rehabilitation - specify

 

 

 

 

 

 

 

 

 

 

__ 10.

Offset/Credit

 

 

 

 

 

 

 

 

 

 

 

 

__ 11.

Refusal to authorize/submit to evaluation with choice of physician/Independent Medical Examination [L. R. S. 23:1121, 1124(B), or 1317.1(F)]

 

 

 

 

 

 

 

 

 

 

 

 

 

__ 12.

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: You may attach a letter or petition with additional information with this disputed claim or when later amending this disputed claim (Form LWC-WC-1008). You must provide a

copy of this claim and any amendment to all opposing parties.

The information given above is true and correct to the best of my knowledge and belief.

SIGNATURE OF CLAIMANT/ATTORNEY

DATE

(circle one)

 

LWC-WC-1008

REV. 4/14

COMPLETE BOTH PAGES

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It is actually easy to fill out the document with this detailed tutorial! Here's what you have to do:

1. You need to fill out the form 1008 properly, therefore be mindful when filling in the sections that contain these blank fields:

Part number 1 in filling out specify

2. Right after completing the last part, head on to the subsequent stage and fill out all required details in all these blank fields - Street or Box, Street or Box, City, City, State Zip, State Zip, Phone, Phone, EMPLOYER, INSURERADMINISTRATOR, circle one, Name, Name, Attn, and Attn.

Phone, State Zip, and Name in specify

3. This 3rd step is considered fairly straightforward, Name, Name, Attn, Relationship, Street or Box, Street or Box, City, City, State Zip, State Zip, Phone, Phone, EMPLOYMENT DATA, Occupation, and Average Weekly Wage Workers - these blanks will need to be filled in here.

Step no. 3 in filling out specify

People often make mistakes while filling out Name in this part. Be sure you read twice everything you type in here.

4. The following section will require your involvement in the subsequent places: A ACCIDENT DATA, Date time and place of accident, Parish of Residence at time of, Accident reported on to whose, Describe the accident and injury, List the names addresses telephone, B MEDICAL DATA, and State the names addresses and. Be sure to provide all required information to go forward.

The best way to prepare specify step 4

5. The last point to finalize this PDF form is essential. Make sure that you fill in the mandatory form fields, which includes Check the following that apply and, No wage benefits have been paid, No medical treatment has been, Occupational Disease, Workers Compensation Rate is, Wage benefits terminated or, Medical treatment, recommended by not authorized, Choice of physician specialty, Disability status, Vocational Rehabilitation specify, OffsetCredit, Refusal to authorizesubmit to, Other, and NOTE You may attach a letter or, before finalizing. Failing to accomplish that can give you a flawed and probably unacceptable form!

Writing section 5 in specify

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