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-6633 - Stop Payment Form ; Form LDOL-WC-1003

MAIL TO: ________________ - ______________ -________

OFFICE OF WORKERS' COMPENSATION SOCIAL SECURITY NUMBER

POST OFFICE BOX 94040

BATON ROUGE, LA 70807 -9040

- _____________ - _______

(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 worker and the OWC 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

5. Purpose of Form: (check one)

[] Payment stopped-Employee working at equal or greater wage [] Payment stopped-Maximum period for paying SEB has expired

[] Payment stopped-Employee able to work at same or greater wage [] 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

1. Temporary total ....................... $ D. Rehabilitation Expenses

2. Supplemental earnings ..............____________________________________ 1. Medical rehabilitation ....................$_________________

3. Permanent partial ..................... 2. Vocational rehabilitation .................._________________

4. Permanent total ........................ 3. Labor Market Survey ......................._________________

5. Death benefits ........................... 4. Evaluation........................................._________________

6. Other benefits .......................... 5. Other................................................_________________

TOTAL INDEMNITY BENEFITS......________________________________________ TOTAL REHABILITATION EPENSES........_________________

(Add A. items 1-6) (Add D. Items 1-5)

B. TOTAL SETTLEMENT AMOUNT $_______________________

C. Medical Expenses E. TOTAL FUNERAL EXPENSES..........$_____________

1. Hospital ..................................$

2. Physician .................................. F. Legal Expenses

3. Diagnostic Tests/Procedures.... 1. Attorney Fees ...............................$ ______________

4. Prescription Drugs.....................____________________________________ 2. Court Costs ................................... ______________

5. Transportation Costs..................____________________________________ 3. Deposition Costs .......................... ______________ _

6. Independent Medical Exams..... 4. Investigation Costs........................ ___________ ___

7. Occupational/Physical Therapy._____________________________________ 5. Penalties and Interest ................... ____________ ___

8. Other............................................. 6. Administrative/Other Costs............ _____________ __

TOTAL MEDICAL EXPENSES............ TOTAL LEGAL EXPENSES ....................... ________________

(Add C. Items 1-8) (Add E. Items 1-5)

G. 3RD PARTY RECOVERIES FOR COSTS ..........$

(NOT INCLUDED ABOVE)

H. TOTAL WORKERS' COMPENSATION COSTS $

(Add A - G)

I . BALANCE OF UNUSED RESERVES..................$

Submitted by:

Preparer's Name: ____________________________________________________________________

Employer/Insurer: ____________________________________________________________________

Address:

Phone: ()

Employer/Insurer NCCI Number: ______________________________________________

Phone: ()

Employer/Insurer NCCI Number:__________________________