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-6661 - Employee's Quarterly Report of Earnings ; Form LDOL-WC-1026

Current through Register Vol. 50, No. 6, June 20, 2024
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, 19
________
and ending, 19___
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.
EMPLOYEE CERTIFICATION
I certify that I can read the English language,
								  that I have this entire document and understand its contents, and that I
								  understand I am held responsible for this information. I certify my answers are
								  complete and true, and certify my compliance with the Louisiana Workers'
								  Compensation Act.
______________________________________________________________________________
								  ________________________________________
PRINT NAME SIGNATURE SOCIAL SECURITY NUMBER
______________________________________________________________________________
								  (_____)__________________________________
ADDRESS CITY STATE / ZIP PHONE NUMBER
__________________________________________
EMPLOYER NAME DATE
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1310.1.