Claims Forms

Injured workers need to complete a variety of forms throughout the claims process. Access the most up to date forms here.

Document

Type

Download

State Mileage Reimbursement Form
Form
ENG
ESP
State Employee Certificate of Compliance Form
Form
ENG
ESP
Medicare Form
Form
ENG
ESP
Medical Authorization Form
Form
ENG
ESP
Longshore Mileage Reimbursement Form
Form
ENG
ESP
Longshore Consent for Release of Payroll Information Form
Form
ENG
ESP
Longshore Choice of Physician Form
Form
ENG
ESP
Employee's Monthly Report of earnings (LDOL Form 1020)
Form
ENG
ESP
Injured Worker First Fill Prescription Form
Form
ENG
ESP
Consent to Release Form
Form
ENG
ESP
Choice of Physician Form (Federal)
Form
ENG
ESP
Choice of Physician Form
Form
ENG
ESP

LWCC is a private, nonprofit mutual insurance company and the largest workers’ compensation carrier in Louisiana. Our purpose is to help Louisiana thrive.

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2237 South Acadian Thruway
Baton Rouge, LA 70808
225-924-7788

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