Request For Compromises Or Lump Sum Settlement
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Request For Compromises Or Lump Sum Settlement Form. This is a Louisiana form and can be use in Workers Comp.
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Tags: Request For Compromises Or Lump Sum Settlement, WC-1011, Louisiana Workers Comp,
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RETURN TO:
OFFICE OF WORKERS' COMPENSATION
POST OFFICE BOX 94040
BATON ROUGE, LA 70804-9040
(225) 342-7565
TOLL FREE (800) 201-3457
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Social Security No.
Date of Injury/Illness
Part(s) of Body Injured
OWC Docket Number
OWC District Number
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REQUEST FOR COMPROMISE
OR LUMP SUM SETTLEMENT
DATE OF APPROVAL
JUDGE
EMPLOYEE
EMPLOYEE'S ATTORNEY
6. Name
7.
Name
Street or Box
Street or Box
City
City
Zip
State
State
Phone
Zip
Phone
EMPLOYER
INSURER/ADMINISTRATOR
(circle one)
8. Name
9. Name
Street or Box
Street or Box
City
City
State
Zip
State
Phone
Zip
Phone
EMPLOYER/INSURER'S ATTORNEY
(circle one)
10. Name
Street or Box
City
Zip
State
Phone
11. DATE OF SETTLEMENT CONFERENCE
12. TERMS AND AMOUNT OF SETTLEMENT:
13. BENEFITS PAID TO DATE:
a.) AVERAGE WEEKLY WAGE:
b.) WORKERS' COMPENSATION BENEFITS:
c.) MEDICAL BENEFITS:
d.) DEATH BENEFITS:
14. ATTORNEY FEES PAID TO DATE:
15. ADDITIONAL FEES REQUIRED:
ATTACHMENTS REQUIRED:
JOINT PETITION
FORM 1007 ATTACHED
OR ON FILE
FORM 1003 ATTACHED
OR ON FILE
EMPLOYEE AFFIDAVIT
EMPLOYER CONCURRENCE
ALLEGATION OF LEGAL REPRESENTATION
MOST RECENT MEDICAL REPORT
WAIVER OF RIGHTS UNDER L.R.S. 23:1271
FILING FEE PAID
ORDER OF APPROVAL
MOTION AND ORDER FOR ATTORNEY FEES
MOTION AND ORDER TO DISMISS 1008
(IF APPLICABLE)
SUBMITTED BY:
PHONE:
LWC-WC-1011
REV. 07/08
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