STATE OF LOUISIANA WORKERS' COMPENSATION SECOND INJURY BOARD POST OFFICE BOX 44187 BATON ROUGE, LOUISIANA 70804-4187 (225) 342-7866 Fax (225) 219-5968 NOTICE OF CLAIM WITH SECOND INJURY FUND CLAIM NUMBER: INJURED EMPLOYEE NAME OF EMPLOYER NAME OF SELF-INSURED/CARRIER DATE OF ACCIDENT: DATE OF NOTICE: SOCIAL SECURITY NUMBER DATE OF FIRST PAYMENT OF COMPENSATION: DATE OF FIRST PAYMENT OF MEDICAL: NAME OF THIRD PARTY HANDLER (IF APPLICABLE) DETAILS OF PRE-EXISTING CONDITION (DATE, MEDICAL REPORTS) DETAILS OF SUBSEQUENT INJURY:(WC-1007, WC-1002, MEDICAL REPORTS KNOWLEDGE STATEMENT) REMARKS: ****************************************************************************** SIGNATURE____________________________________ CARRIER/SELF-INSURED_______________________ ADDRESS______________________________________ CITY___________________________________________ PHONE________________________________________ NOTE: A NOTICE OF CLAIM MUST BE FILED WITH THE SECOND INJURY BOARD WITHIN 52 WEEKS AFTER THE FIRST PAYMENT OF ANY INDEMNITY OR MEDICAL BENEFITS PAID IN ACCORDANCE WITH THE ACT. SIB Form A American LegalNet, Inc. www.FormsWorkflow.com