EMPLOYEE'S MONTHLY REPORT OF EARNINGS You must submit this report to your employer's workers' compensation insurer within 30 days of your job-related injury, and every 30 days as long as you receive workers' compensation indemnity benefits. You do not have to submit this report if you have only received medical benefits. Your workers' compensation benefits may be suspended if you do not timely submit this report. Warning: Per L.R.S. 23:1208 of the Louisiana Workers' Compensation Statute, it shall be unlawful for a person, for the purpose of obtaining or defeating any benefit payment under the provisions of this Chapter, either for himself or for any other person, to willfully make a false statement or representation. Penalties for violations include imprisonment, fines, and/or the forfeiture of benefits. DO NOT leave any blanks on this report. appropriate. 1. Print or type all responses, and use Not Applicable (N/A) or Zero ( 0-) where - The information in this report is true for the period beginning _________________________, 20___ and ending _____________________, 20 ____. For the period covered in this report, did you receive a salary, wage, sales commission, or payment, including cash, of any kind? Yes No If yes, give name and address of employer __________________________________________________________________ If yes, give your gross earnings___________________________________________________________________________ 2. 3. For the period covered in this report, were you self-employed or involved in any business enterprise? These include but are not limited to farming, sales work, operating a business (even if the business lost money), child care, yard work, mechanical work, or any type of family business. Yes No If yes, describe the type of business you are involved in, your job duties, and the amount of income received from the business. ____________________________________________________________________________________________ ____________________________________________________________________________________________________ 4. Did you perform any volunteer work during the period covered in this report? Yes No If yes, describe the type of volunteer work you performed. _____________________________________________________ 5. Did you receive any unemployment insurance benefits for the period covered in this report? If yes, how much? __________________ For how many weeks? ____________ 6. Did you receive any old age insurance benefits under Title II of the Social Security Act? If yes, how much? ___________________ 7. Did you receive any Social Security Disability Benefits, retirement benefits, or any other type of disability or government benefits? Yes No If yes, how much? _______________ What type of benefits did you receive? ___________________________________ Employee Certification I certify that I understand the contents of this entire document and understand I am held responsible for this information. I certify my answers are complete and true, and certify my compliance with the Louisiana Workers' Compensation Act. ________________________________________________ Print Name Signature Yes No _ Yes No ________________________________________________ Social Security Number Date ________________________________________________ Physical/Street Address City State/Zip _____(_________)___________________________________ Telephone Number ________________________________________________ Date of Injury LWC-WC 1020 REVISED 07/08/2008 Claim Number ____________________________(______)______________ Insurer Telephone Number American LegalNet, Inc. www.FormsWorkflow.com