Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 1 - General Administration › Chapter 1 - General Provisions › Section I-105 - Forms

Current through Register Vol. 50, No. 6, June 20, 2024
A. The following
				  forms are prescribed for use as required by the Workers' Compensation Act and
				  these rules.
1. Form LDOL-WC-1007, Employer's
				  Report of Occupational Injury or Disease, shall be filed with the Office of
				  Workers' Compensation and with the employer's insurer when required by
				  R.S.
				  23:1306, or within seven days of the first
				  mediation conference of a disputed claim for benefits, whichever comes first.
				  Failure to file this form as required may be penalized pursuant to LAC
				  40:I.109.
2. Form LDOL-WC-1020,
				  Employee's Monthly Report of Earnings, shall be filed with the employer's
				  insurer by employees who receive workers' compensation indemnity disability
				  benefits within 30 days of their job-related injury, and every 30 days
				  thereafter as long as they receive workers' compensation indemnity disability
				  benefits. This form does not have to be filed by employees who only have
				  received medical benefits. Failure to file this form as required may result in
				  a suspension of benefits.
3. Form
				  LDOL-WC-1025
a. Form LDOL-WC-1025, Employee
				  and Employer Certificate of Compliance, shall be filed with the employer's
				  insurer after Form LDOL-WC-1007 has been filed with the Office of Workers'
				  Compensation. Employers who fail to file this form as required are subject to a
				  penalty of $500, payable to the insurer.
b. Form LDOL-WC-1025, Employee and Employer
				  Certificate of Compliance, shall be filed with the employer's insurer by
				  employees within 14 days of their receipt of the form, after Form LDOL-WC-1007
				  has been filed with the Office of Workers' Compensation. Employees who fail to
				  file this form as required may have their benefits suspended; after this form
				  is filed, employees are entitled to all suspended benefits, if otherwise
				  eligible for benefits.
4. Form LDOL-WC-1026, Employee's Quarterly
				  Report of Earnings, shall be filed with the employer's insurer by employees
				  within 14 days of receipt of the form. This form does not have to be filed by
				  employees who only have received medical benefits, or by employees who have
				  timely filed all necessary LDOL-WC-1020 Forms. Employees who fail to file this
				  form as required may have their benefits suspended; after this form is filed,
				  employees are entitled to all suspended benefits, if otherwise eligible for
				  benefits.
5. Form LDOL-WC-1017A
a. Form LDOL-WC-1017A, Employer's Report of
				  Occupational Injury and Illness Quarterly Summary, shall be filed with the
				  Office of Workers' Compensation by the last day of the first month of the
				  succeeding quarter by all employers with 11 or more employees at any one time
				  in the prior calendar year.
b. The
				  following employers are exempt from the requirements of
				  §105.
				  A.5.a [also identified by their Standard
				  Industrial Classification Codes (SIC Codes)]:
i.
agricultural production (SIC 01);
ii.
agricultural services (SIC 07);
iii.
automotive dealers and gasoline service stations
								(SIC 55);
iv.
apparel and accessory stores (SIC 56);
v.
furniture, home furnishings, and equipment stores
								(SIC 57);
vi.
eating and drinking places (SIC 58);
vii.
miscellaneous retail (SIC 59);
viii.
banking (SIC 60);
ix.
credit agencies other than banks (SIC 61);
x.
security, commodity brokers, and services (SIC
								62);
xi.
insurance (SIC 63);
xii.
insurance agents, brokers, and services (SIC
								64);
xiii.
real estate (SIC 65);
xiv.
holding and other investment offices (SIC
								67);
xv.
personal services (SIC 72);
xvi.
business services (SIC 73);
xvii.
motion pictures (SIC 78);
xviii.
legal services (SIC 81);
xix.
educational services (SIC 82);
xx.
social services (SIC 83);
xxi.
museums, botanical, and zoological gardens (SIC
								84);
xxii.
membership organizations (SIC 86);
xxiii.
engineering, accounting, research and management
								(SIC 87);
xxiv.
private households (SIC 88);
xxv.
miscellaneous services (SIC 89);
xxvi.
offices and clinics of doctors of medicine (SIC
								8011);
xxvii.
offices and clinics of dentists (SIC 8021);
xxviii.
offices and clinics of doctors of osteopathy (SIC
								8031);
xxix.
offices and clinics of chiropractors (SIC
								8041);
xxx.
offices and clinics of optometrists (SIC
								8042);
xxxi.
offices and clinics of podiatrists (SIC
								8043);
xxxii.
offices and clinics of health practitioners, not
								elsewhere classified (SIC 8049);
xxxiii.
medical laboratories (SIC 8071);
xxxiv.
dental laboratories (SIC 8072);
xxxv.
home health care services (SIC 8082);
xxxvi.
kidney dialysis centers (SIC 8092);
xxxvii.
specialty outpatient facilities, not elsewhere
								classified (SIC 8093);
xxxvii.
health and allied services, not elsewhere
								classified (SIC 8099)
c.
				  Failure to file this form as required may be penalized pursuant to LAC
				  40:I.109.