La. Admin. Code tit. 40 § I-6657
Current through Register Vol. 50, No. 6, June 20, 2024
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 |
La. Admin. Code tit. 40, § I-6657