La. Admin. Code tit. 40 § I-6633
MAIL TO: ________________ - ______________ -________ OFFICE OF WORKERS' COMPENSATION SOCIAL SECURITY NUMBER POST OFFICE BOX 94040 BATON ROUGE, LA 70807 -9040 - _____________ - _______ (225) 342-7565, TOLL FREE (800) 201-3457 DATE OF INJURY/ILLNESS STOP PAYMENT FORM This form is sent by the Employer/Insurer to the injured worker and the OWC within 30 days of the closure of a case. An AMENDED COPY is required if the case re-opens or additional costs are incurred. 1. __________________________________________________________________________________________ 2. __________________ - _ - ________ (Employee) (Date of Birth) Date of this Notice 3. __________________________________________________________________________________________ 4. __________________ - ______________ - ________ Part(s) of Body Injured Date Compensation Paid Through 5. Purpose of Form: (check one) [] Payment stopped-Employee working at equal or greater wage [] Payment stopped-Maximum period for paying SEB has expired [] Payment stopped-Employee able to work at same or greater wage [] Payment stopped-3rd Party recovery without notice [] Payment stopped-Lump sum/Compromise settlement approved [] Amend or correct prior 1003 [] Other _______________________________________________ 6. Length of Disability ____________________ weeks ____________________________ days. 7. Give ICD - 9 Diagnostic code(s)______________________________________________________________________ . 8. Give CPT Procedure code(s) ._____________________________________________________________________________________________________________________ 9. COSTS INCURRED FOR THIS CASE: A. Indemnity Benefits 1. Temporary total ....................... $ D. Rehabilitation Expenses 2. Supplemental earnings ..............____________________________________ 1. Medical rehabilitation ....................$_________________ 3. Permanent partial ..................... 2. Vocational rehabilitation .................._________________ 4. Permanent total ........................ 3. Labor Market Survey ......................._________________ 5. Death benefits ........................... 4. Evaluation........................................._________________ 6. Other benefits .......................... 5. Other................................................_________________ TOTAL INDEMNITY BENEFITS......________________________________________ TOTAL REHABILITATION EPENSES........_________________ (Add A. items 1-6) (Add D. Items 1-5) B. TOTAL SETTLEMENT AMOUNT $_______________________ C. Medical Expenses E. TOTAL FUNERAL EXPENSES..........$_____________ 1. Hospital ..................................$ 2. Physician .................................. F. Legal Expenses 3. Diagnostic Tests/Procedures.... 1. Attorney Fees ...............................$ ______________ 4. Prescription Drugs.....................____________________________________ 2. Court Costs ................................... ______________ 5. Transportation Costs..................____________________________________ 3. Deposition Costs .......................... ______________ _ 6. Independent Medical Exams..... 4. Investigation Costs........................ ___________ ___ 7. Occupational/Physical Therapy._____________________________________ 5. Penalties and Interest ................... ____________ ___ 8. Other............................................. 6. Administrative/Other Costs............ _____________ __ TOTAL MEDICAL EXPENSES............ TOTAL LEGAL EXPENSES ....................... ________________ (Add C. Items 1-8) (Add E. Items 1-5) G. 3RD PARTY RECOVERIES FOR COSTS ..........$ (NOT INCLUDED ABOVE) H. TOTAL WORKERS' COMPENSATION COSTS $ (Add A - G) I . BALANCE OF UNUSED RESERVES..................$ Submitted by: Preparer's Name: ____________________________________________________________________ Employer/Insurer: ____________________________________________________________________ Address: Phone: () Employer/Insurer NCCI Number: ______________________________________________ Phone: () Employer/Insurer NCCI Number:__________________________ |
La. Admin. Code tit. 40, § I-6633