The following forms are commonly used in processing workers' compensation claims. You may not need to complete them all. They are here for your convenience. Your claims representative should let you know when the completion of a form is required.
Choice of PhysicianWorkers' compensation law allows you one choice of physician per healthcare specialty. Use this form to designate your choice.
Earnings Report (LDOL-WC 1020)If you receive any type of disability payment from LWCC, you are required to report any and all earning you receive during the time you receive any type of disability benefits from LWCC. Use this form to report those earnings.
Employee Certificate of Compliance (LDOL-WC 1025.EE)By signing this form you acknowledge certain forms of workers' comp fraud and the penalties for committing fraud. Your certification that you have read the document is required by workers' comp law.
Authorization for Medical RecordsState law grants your employers and their designated workers' compensation company access to medical records related to the treatment of your work-related injury in order to properly process your claim. This form lets you know that LWCC will have access to your medical records.
Mileage LogYou are entitled to a mileage reimbursement of $.36 (36 cents) per mile for traveling to receive healthcare to treat your work-related injury. To receive reimbursement, complete this log on a monthly basis and submit it to your LWCC claims representative.