La. Admin. Code tit. 40 § I-6661
EMPLOYEE'S QUARTERLY REPORT OF EARNINGS | ||||
You must submit this Report to your workers' compensation insurer within 14 days. Your workers' compensation benefits may be suspended if you do not timely submit this Report. You would be entitled to all suspended benefits after this report is provided to your Insurer, if you are otherwise eligible for benefits. You do not have to file this report if you have timely filed all necessary LDOL-WC-1020 Forms, or if you have only received medical benefits. | ||||
DO NOT leave any blanks on this Report. Print or type all responses, and use N/A (not applicable) or -0- (zero) where appropriate. 1. The information in this Report is true for the period beginning, 19 ________ and ending, 19___ 2. The name and address of the employer that I am receiving benefits from is: _____________________________________________________________ __________________________________________________________________________________________________________________________ 3. Did you work for this employer in the past quarter? ________________________________________________________ If yes, how much were your gross wages? $ ________________________________ 4. Did you work for any other employer in the past quarter? ________________________________________ If yes, the name and address of the employer is ___________________ ___________________________________________________________________________If yes, how much were your gross wages? $ _____________ 5. Did you have any earnings through self employment in the past quarter? If yes, how much? $ __________________ 6. Did you receive any unemployment compensation benefits in the past quarter? __________ If yes, how much? $____________________ 7. I received $ ________________________ in old age benefits under Title ll of the Social Security Act. 8. I received $ in Social Security Disability Benefits or other disability benefits. | ||||
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-6661