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-6662 - Attorney Fee Notice of Lien ; Form LDOL-WC-1027

Universal Citation: LA Admin Code I-6662
Current through Register Vol. 50, No. 9, September 20, 2024

Attached hereto and designated as "Attachment Number 16."

DOCKET NO.:________________

CLAIMANT:__________________________________

REPRESENTATIVES:|___________________

EMPLOYER:________________________________________

NOTICE OF LIEN

Pursuant to Section 5547(B) of the hearing rules of the Office of Workers' Compensation Administration,____________________________________ serves notice upon this Honorable Court and all parties to the above entitled claim that (he/she/it) represented the claimant from (date) to (date) and hereby asserts a lien on the proceeds of the claim for unpaid attorney fees.

Respectfully submitted,

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1310.1.

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