Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 3 - Hearing Rules
Chapter 66 - Miscellaneous
Subchapter E - Forms
Section I-6631 - Notice of Payment, Modification, Suspension, Termination or Controversion of Compensation or Medical Benefits
Current through Register Vol. 50, No. 9, September 20, 2024
EMPLOYER/PAYOR MAIL TO:
1. Employee Social Security No. ______-_____-_______
OFFICE OF WORKERS' COMPENSATION
2. Payor Claim No.: _____________________________
POST OFFICE BOX 94040
3. Date of Injury/Illness _________________________
BATON ROUGE, LA 70804-9040
4. Date of Notice: ______________________________
NOTICE OF PAYMENT, MODIFICATION, SUSPENSION, TERMINATION OR CONTROVERSION
OF COMPENSATION OR MEDICAL BENEFITS
5. Purpose of Form (check one):
Initial Payment ____ Modification ____ Suspension ____ Termination____ Controversion ____
6.
Address: ______________________________________________
Telephone: ______________________________________________
Address: ______________________________________________
Telephone: ______________________________________________
Facsimile: ______________________________________________
Address: ______________________________________________
______________________________________________
Telephone: ______________________________________________
Facsimile: ______________________________________________
7. Effective Date of Initial Payment, Modification, Suspension, Termination or Controversion:______/______/20_____
8. Description of Injury/Occupational Disease: ______________________________________________________________________________________
9. Average Weekly Wage: $__________________
10. Payment/Modification (check one): Initial Payment ____ Modification____
Indemnity Benefits are to be paid as follows:
SEB paid at the rate of $ _______________ per ________________ dependent on wages as reflected in LWC-WC-1020's to be submitted by
employee each month;
_____ Social Security Benefits at the rate of $______________ per _____________;
_____ Other Workers' Compensation Benefits at the rate of $__________ per _________'
_____ Employer Funded Disability Benefits at the rate of $___________ per __________;
_____ Unemployment Insurance Benefits
_____ Third Party Recovery in the amount of $_______________
_____ 50% reduction of compensation based on Employee's refusal to cooperate with Vocational Rehabilitation
_____ Reduction due to child support order
_____ Other (Describe): _____________________________________________________________________________________________________
Employee Name __________________
Date of injury/illness________________
11. Suspension/Termination
Indemnity and/or Medical Benefits have been suspended/terminated due to:
_____ Employee's refusal to submit to a medical examination;
_____ Employee's refusal to execute a Choice of Physician form;
_____ Fraud
_____ Dispute over Compensability (Describe):
________________________________________________________
|_________________________________________________________
_______________________
_____ Employee's refusal to return the form LWC-WC-1025 or LWC-WC-1020;
_____ Released to return to work full duty;
_____ Employee able to earn 90% of pre-accident average weekly wage; or
____ Other (Describe):
________________________________________________________
|_________________________________________________________
_______________________
12. Controversion
Employee's rights to Indemnity and/or Medical Benefits are disputed and have been denied because Employer/Payor disputes:
_____ Compensable Work Accident;
_____ Compensable Injury;
_____ Employment Relationship;
_____ Causation;
_____ Disability;
_____ Fraud;
_____ Jurisdiction; or
____ Other (Describe):
________________________________________________________
|_________________________________________________________
_______________________
13. Notice Submitted By:______________________
Signature of Preparer:________________________
Printed name:_______________________
Position/Affiliation: ______________________
Telephone: _____________________
Facsimile: _____________________
Address: _________________
________________________________________________________
|_________________________________________________________
14. Please provide the following information:
Payor/Self Insured Employer Name:____________________________________________
Telephone: ___________________________
Facsimile: _______________________________
Address: ___________________________________
NOTICE OF DISAGREEMENT
(to be completed by Employee/Employee Representative)
MAIL TO: Employee Social Security No.: _______-____-________
The preparer for Employer/Payor Payor Claim No. (if known): _______________________________
at the address listed in Section 13 Date of Injury/Illness: _______________________________
of the LWC-WC-1002. Date of Notice of Disagreement:
BASIS OF DISAGREEMENT
1. Average Weekly Wage is incorrect. The correct AWW amount is $______________.
2. The type of workers' compensation indemnity benefits is incorrect. The correct type is PTD/TTD/SEB/PPD (circle one).
3. The amount/rate of workers' compensation indemnity benefits is incorrect. The correct amount is $_________ per __________.
4. The basis for Employer/Payor's suspension/termination/controversion of benefits is incorrect because (describe):
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
5. Other (describe): ________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
6. Notice Submitted By:
Employee Name:__________________________
Telephone _________________________
Address: ____________________________
____________________________
Employee Representative ____________________________
La. Bar Roll No.____________________________
Address:____________________________
____________________________
Telephone: ____________________________
Facsimile:____________________________
Signature ____________________________
Printed name: ____________________________
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1310.1.
