EMPLOYER CERTIFICATE OF COMPLIANCE You must submit this Certification to your workers' compensation insurer. Failure to submit this Certification as required may result in your being penalized by a fine of $500, payable to your insurer. You must secure workers' compensation for your employees through insurance or by becoming an authorized selfinsured. If you fail to provide security for workers' compensation, you must pay an additional 50% in weekly benefits to your injured workers. If you willfully fail to provide security for workers' compensation, then you are subject to a fine of up to $10,000, imprisonment with or without hard labor for not more than 1 year, or both. If you have been previously fined and again fail to provide security for workers' compensation, then you are subject to additional penalties, including a court order to cease and desist from continuing further business operations. You must not collect, demand, request, or accept any amount from any employee to pay or reimburse for the workers' compensation insurance premium. If you violate this provision, you may be punished with a fine of not more than $500, or imprisoned with or without hard labor for not more than one year, or both. It is unlawful for you to willfully make, or to assist or counsel someone else to make, a false statement or representation in order to obtain or to defeat workers' compensation benefits. If you violate this provision, you may be fined up to $10,000, imprisoned with or without hard labor for up to 10 years, or both depending on the amount of benefits unlawfully obtained or defeated. In addition to these criminal penalties, you may be assessed a civil penalty of up to $5,000. EMPLOYER CERTIFICATION I certify that I have read this entire document and understand its contents, and that I understand I am held responsible for this information. I certify my compliance with the Louisiana Workers' Compensation Act. Preparer Name (PRINT) Signature Date Company Name ( ) Phone Number Company Address Insurance Policy Number Employee Social Security Number Employee Name LWC-WC-1025.ER REV. 7/08 American LegalNet, Inc. www.FormsWorkflow.com