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-6659 - Employee and Employer Certificate of Compliance ; Form LDOL-WC-1025

Current through Register Vol. 50, No. 6, June 20, 2024
EMPLOYEE
CERTIFICATE OF COMPLIANCE
You must submit this form to your
								  employer's workers' compensation insurer or to your employer within 14 days of
								  its receipt
. Your workers' compensation
benefits may be suspended
								  if you do not timely submit this Certification.
You would be entitled to
								  all suspended benefits after this Certification is provided to your insurer, if
								  you are otherwise eligible for benefits.
It is unlawful for you to work and receive
								  workers' compensation indemnity disability, except for supplemental earnings
								  benefits. Supplemental earnings benefits are paid when an employee is able to
								  work, but is unable to earn 90 percent or more of his pre-injury wages as a
								  result of a job related accident. As an injured worker, you must notify your
								  employer or insurer of the earning of any wages, changes in employment or
								  medical status, receipt of unemployment benefits, receipt of Social Security
								  benefits and receipt of retirement benefits. If you receive benefits for more
								  than 30 days, you will be required to certify your earnings to your insurer
								  quarterly.
It is unlawful for you to receive workers'
								  compensation indemnity disability benefits and unemployment benefits at the
								  same time, except for permanent partial disability benefits. Permanent partial
								  disability benefits are paid solely for amputation or for anatomical loss of
								  use of a body part or function. If you violate this provision, you may be fined
								  up to $10,000, imprisoned up to 90 days, or both.
It is unlawful for you to willfully make, or to
								  assist or counsel someone else to make, a false statement or representation in
								  order to obtain or to defeat workers' compensation benefits. If you violate
								  this provision, you may be fined, imprisoned, or both, as follows:
Unlawful Benefits
Fine
Imprisonment
$10,000 or more
up to
										  $10,000
up to 10 years, with or without hard labor
$2,500 or more but less
than $10,000
up to $
										  5,000
up to 5 years, with or without hard labor
less than $2,500
up to
										  $500
up to 6 months
In addition to these criminal penalties, you may
								  be assessed a civil penalty of up to $5,000 and may forfeit your right to
								  receive workers' compensation benefits.
EMPLOYEE
								  CERTIFICATION
I certify that I can read the English language,
								  that I have read this entire document and understand its contents, and that I
								  understand I am held responsible for this information. I certify my compliance
								  with the Louisiana Workers' Compensation Act.
__________ ____________________ |_______________
Print Name Signature Social Security Number Date
_______________________________________
()
Address City State / Zip Phone Number
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1310.1.