ANNUAL REPORT OF WORKERS' COMPENSATION COSTS FOR CALENDAR YEAR _____________ 1. EMPLOYER INFORMATION Account # Name: Address: City, St., Zip: Contact Person: Phone #: Fed EIN: ( 3. Coverage Provided: 2. INSURANCE COMPANY INFORMATION Account # Name: Address: City, St. Zip: Contact Person: Phone #: Phone Number: ) Self-insured / Excess Insurance Conventional Workers' Compensation Policy Combination of Insurance Policies [R.S. 23:1168(A)(2)] 4. COSTS INCURRED DURING THE CALENDAR YEAR (See Instructions) Paid by Employer A. Indemnity Benefits: 1. Temporary Total 2. Supplemental Earnings 3. Permanent Partial 4. Permanent Total 5. Death Benefits 6. Other Compensation TOTAL INDEMNITY BENEFITS B. TOTAL COMPROMISE/LUMP SUM SETTLEMENTS: C. Medical Expenses: 1. Hospital 2. Physicians 3. Diagnostic Tests/Procedures 4. Prescription Drugs 5. Transportation 6. Independent Medical Exams 7. Physical/Occupational Therapy 8. Other TOTAL MEDICAL EXPENSES D. Rehabilitation Expenses 1. Vocational Rehabilitation 2. Labor Market Surveys 3. Evaluations 4. Other TOTAL REHABILITATION EXPENSES Paid by Insurance LWC-WC-1000 REV. 01/10 American LegalNet, Inc. www.FormsWorkFlow.com Paid by Employer E. TOTAL FUNERAL EXPENSES F. Legal Expenses 1. Attorney Fees 2. Court Costs 3. Deposition Costs 4. Investigation Costs 5. Penalties and Interest 6. Administrative/Other Costs TOTAL LEGAL EXPENSES G. Cost Summary 1. Total Indemnity Benefits (ITEM A) 2. Total Compromise/Lump Sum Settlements (ITEM B) 3. Total Medical Expenses (ITEM C) 4. Total Rehabilitation Costs (ITEM D) 5. Total Funeral Expenses (ITEM E) 6. 3rd Party Recoveries for Costs (not included above) 7. Total Assessable Costs (1+2+3+4+5-6) 8. Total Legal Expenses (ITEM F) 9. TOTAL WORKERS' COMPENSATION COSTS H. Number of Claims Summary 1. Carried over from prior year 2. Opened during current year 3. Closed during current year 4. Open at year end ( 1 + 2 - 3) 5. Total Medical only claims I. OPEN RESERVE CLAIMS (at year end) Number Amount Paid by Insurance NOTE: The amount of compensation benefits paid will be used by the Director to make assessments for the administration of the Workers' Compensation Office under the provisions of Act 29, 1983, R.S. 23:1291.1 All other information submitted will be used for statistical records only with the names of employers and carriers being confidential and privileged. (LA R.S. 23:1293) FOR OFFICIAL USE ONLY I certify that the information contained herein is true and correct to the best of my knowledge and belief. _________________________________________ Signature Date RETURN TO: ATTN: AUDIT & COMPLIANCE OFFICE OF WORKERS' COMPENSATION P.O BOX 94040 BATON ROUGE, LA 70804-9040 (225) 342-5658 (PHONE) (225) 342-7578 (FAX) LWC-WC-1000 REV. 01/10 American LegalNet, Inc. www.FormsWorkFlow.com