Mail To: LOCAL DISTRICT OFFICE OR 1. 2. 3. 4. 5. 6. Docket Number Social Security No. Date of Injury/Illness Part(s) of Body Injured Date of This Request Date of Hire Date of Birth - - - OFFICE OF WORKERS' COMPENSATION POST OFFICE BOX 94040 BATON ROUGE, LA 70804-9040 For information call (225) 342-7565 or Toll Free (800) 201-3457. - - DISPUTED CLAIM FOR COMPENSATION 7. This claim is submitted by: __ Employee __ Employer __ Insurer __ Dependent __ Health Care Provider __ LWC __ Other GENERAL INFORMATION Claimant files this dispute with the Office of Workers' Compensation. This office must be notified immediately in writing of changes in address. An employee may be represented by an attorney, but it is not required. EMPLOYEE 8. Name Street or Box City State Phone ( ) Zip 9. Name Street or Box City State Phone ( ) EMPLOYEE'S ATTORNEY Zip EMPLOYER INSURER/ADMINISTRATOR (circle one) 11. Name Attn: Street or Box City Zip State Phone ( ) Zip 10. Name Attn: Street or Box City State Phone ( ) EMPLOYER/INSURER'S ATTORNEY (circle one) 12. Name Attn: Street or Box City State Phone ( ) Zip 13. Name Relationship Street or Box City State Phone ( ) DEPENDENT/HCP/OTHER (circle one) Zip 14. EMPLOYMENT DATA Occupation: Average Weekly Wage $ Workers' Compensation Rate $ LWC-WC-1008 REV. 2/09 COMPLETE BOTH PAGES American LegalNet, Inc. www.FormsWorkflow.com 15. TO BE COMPLETED BY INJURED EMPLOYEE OR DEPENDENT: (A) ACCIDENT DATA Date, time and place of accident: Parish of Residence at time of Injury/Illness Accident reported on / / , to whose position with the employer is Describe the accident and injury in detail (person/equipment involved, type of injury, etc.) List the names, addresses, telephone numbers of any witnesses. (B) MEDICAL DATA State the names, addresses, and telephone numbers of hospitals, clinics and doctors who have provided medical attention. (C) THE BONA-FIDE DISPUTE Check the following that apply and fill in the blanks: __ 1. __ 2. __ 3. __ 4. __ 5. __ 6. No wage benefits have been paid No medical treatment has been authorized Occupational Disease Workers' Compensation Rate is Incorrect - Should be $ Wage benefits terminated or reduced on Medical treatment (Procedure/Prescription) recommended by __ 7. __ 8. __ 9. __ 10. __ 11. __ 12. Choice of physician (specialty) Disability status Vocational Rehabilitation - specify Offset/Credit Refusal to authorize/submit to evaluation with choice of physician/Independent Medical Examination [L. R. S. 23:1121, 1124(B), or 1317.1(F)] Other: not authorized. / / NOTE: You may attach a letter or petition with additional information with this disputed claim or when later amending this disputed claim (Form LWC-WC-1008). You must provide a copy of this claim and any amendment to all opposing parties. The information given above is true and correct to the best of my knowledge and belief. SIGNATURE OF CLAIMANT/ATTORNEY (circle one) DATE LWC-WC-1008 REV. 2/09 COMPLETE BOTH PAGES American LegalNet, Inc. www.FormsWorkflow.com