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-6655 - Employer's Report of Occupational Injury and Illness Quarterly Summary ; Form LDOL-WC-1017A

EMPLOYEE'S QUARTERLY REPORT OF EARNINGS

You must submit this Report to your workers' compensation insurer within 14 days. Your workers' compensation benefits may be suspended if you do not timely submit this Report. You would be entitled to all suspended benefits after this report is provided to your Insurer, if you are otherwise eligible for benefits.

You do not have to file this report if you have timely filed all necessary LDOL-WC-1020 Forms, or if you have only received medical benefits.

DO NOT leave any blanks on this Report. Print or type all responses, and use N/A (not applicable) or -0- (zero) where appropriate.

1. The information in this Report is true for the period beginning ______________________________________ , 20 ________ and ending, 20 .

2. The name and address of the employer that I am receiving benefits from is: _________________________________________________________

3. Did you work for this employer in the past quarter?_____________________________________________________________________________

If yes, how much were your gross wages? $ ________________________________________

4. Did you work for any other employer in the past quarter? If yes, the name and address of the employer is_______________ If yes, how much were your gross wages? $__________

5. Did you have any earnings through self employment in the past quarter? If yes, how much? $_____________

6. Did you receive any unemployment compensation benefits in the past quarter? __________ If yes, how much? $______________

7. I received $ ________________________ in old age benefits under Title ll of the Social Security Act.

8. I received $ in Social Security Disability Benefits or other disability benefits.