MAIL TO: OFFICE OF WORKERS' COMPENSATION POST OFFICE BOX 94040 BATON ROUGE, LA 70804-9094 (225) 342-7565, TOLL FREE (800) 201-3457 STOP PAYMENT FORM __________-__________-__________ SOCIAL SECURITY NUMBER ___________________________ DATE OF INJURY/ILLNESS This form is sent by the Employer/Insurer to the injured workers and the OWCA within 30 days of the closure of a case. An AMENDED COPY is required if the case re-opens or additional costs are incurred. 1. 3. 1. ____________________________________________ (Employee) (Date of Birth) ____________________________________________ Part(s) of Body Injured Purpose of Form: (check one) _ Payment stopped-Employee working at equal or greater wages _ Payment stopped-Employee able to work at same or greater wages _ Payment stopped-Lump sum/Compromise settlement approved _ Other___________________________________________ Length of Disability__________weeks__________days. Give ICD - 9 Diagnostic code(s)________________________________ 2. __________-__________-__________ Date of this Notice __________-__________-__________ Date Compensation Paid Through 4. _ Payment stopped-Maximum period for paying SEB has expired _ Payment stopped-3rd Party recovery without notice _ Amend or correct prior 1003 6. 7. Give CPT Procedure code(s)__________________________________ 8. __________________________________________________________________________________________________________________________ 9. COSTS INCURRED FOR THIS CASE: A. Indemnity Benefits 1. Temporary total 2. Supplemental earnings 3. Permanent partial 4. Permanent total 5. Death Benefits 6. Other Benefits _________________ _________________ _________________ _________________ _________________ _________________ D. Rehabilitation Expenses 1. Medical Rehabilitation 2. Vocational Rehabilitation 3. Labor Market Survey 4. Evaluation 5. Other _________________ _________________ _________________ _________________ _________________ TOTAL INDEMNITY BENEFITS (Add A. Items 1-6) B. C. TOTAL SETTLEMENT AMOUNT Medical Expenses 1. Hospital 2. Physician 3. Diagnostic Tests/Procedures 4. Prescription Drugs 5. Transportation Costs 6. Independent Medical Exams 7. Occupational/Physical Therapy 8. Other $0.00 $________________ $________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ TOTAL REHABILITATION EXPENSES (Add D. Items 1-5) E. TOTAL FUNERAL EXPENSES F. Legal Expenses 1. Attorney Fees 2. Court Costs 3. Deposition Costs 4. Investigative Costs 5. Penalties and Interest 6. Administrative/Other Costs $0.00 $________________ $________________ _________________ _________________ _________________ _________________ _________________ _________________ TOTAL MEDICAL EXPENSES (Add C. Items 1-8) 0.00 $________________ TOTAL LEGAL EXPENSES (Add F. Items 1-6) 0.00 $________________ $________________ G. 3RD PARTY RECOVERY FOR COSTS (Not Included Above) H. TOTAL WORKERS' COMPENSATION COSTS (Add A-G) I. BALANCE OF UNUSED RESERVES Submitted by: Preparer's Name: ________________________________ Employer/Insurer: ________________________________ Address: _______________________________________ _______________________________________________ Phone: ( ) ___________________________________ 0.00 $________________ $________________ Employee Name: __________________________________ Employer: ________________________________________ Address: _________________________________________ _________________________________________________ Phone: ( ) _____________________________________ Employer/Insurer NCCI Number:_____________________ LWC-WC-1003 REV. 07/08 American LegalNet, Inc. www.FormsWorkflow.com