MAIL TO: OFFICE OF WORKERS' COMPENSATION POST OFFICE BOX 94040 BATON ROUGE, LA 70804-9040 (225) 342-7565 TOLL FREE (800) 201-3457 1. Social Security No . - 2. Date of Injury/Illness - - NOTICE OF PAYMENT This form is to be completed by the Employer/Insurer and sent to the injured employee with the first check or within 10 days of suspension/modification and/or change to SEB. A copy must be sent to the Office of Workers' Compensation Administration within 10 days of the effective date. Purpose of Form (check one): __ Payment __ Modification 3. 4. __ Change to SEB 5. Effective Date Part(s) of Body Injured 7. Suspension Employee Name 6. __ Nature of Injury 8. __ __ B. Payments re-started at $ per week. __ C. Payments reduced by $ __ Social Security Benefits __ Employer Disability Benefits __ Third Party Recovery __ Other: due to: __ Other Workers' Compensation Benefits __ Unemployment Insurance Benefits __ Refused Rehabilitation __ D. Permanent Partial Benefits of $ weeks. __ E. Supplemental Earnings Benefits of $ The exact amount received weekly may vary. __ F. Death Benefits have begun in the amount of $ % of wages. representing __ G. Payment suspended due to employee failing to cooperate. __ 9. Compensation is paid as follows: A. Weekly payments of $ begun. H. Other reasons or explanations based on an average weekly wage of $ have will be paid for will begin per week, Submitted by: Preparer's Name: Employee Name: Employer/Insurer: Employer: Address: Address: Phone: ( ) ____ Phone : ( ) Employer/Insurer NCCI Number: LWC-WC-1002 REV. 07/08 American LegalNet, Inc. www.FormsWorkflow.com