LOUISIANA DEPARTMENT OF LABOR SECOND INJURY BOARD P. O. BOX 44187 BATON ROUGE, LA 70804-4187 SIF CLAIM NO. CARRIERS CLAIM NO. DATE OF ACCIDENT EMPLOYEE: CARRIER/SELF-INS. EMPLOYER: DISABILITY BENEFITS PROVIDED TO INJURED EMPLOYEE WEEKLY FROM - TO THIS TOTAL WEEKS THIS AMOUNT RATE SUBMISSION SUBMISSION TTD PTD SEB DEATH SETTLEMENT TOTAL INDEMNITY PAID THIS SUBMISSION $ TOTAL MEDICAL BENEFITS PAID THIS SUBMISSION $ ************************************************************************ ****************************** MEDICAL REIMBURSEMENT REQUEST THE FOLLOWING MUST BE PROVIDED: A. AN ITEMIZED LIST OF ALL MEDICAL EXPENSES IN CHRONOLOGICAL ORDER. B. COPIES OF ALL MEDICAL BILLS ATTACHED AND NUMBERED TO CORRESPOND WITH ITE MIZED LIST. MEDICAL BILLS SHOULD BE IN CHRONOLOGICAL ORDER. C. COPIES OF DRAFTS OR COMPUTER PRINTOUT TO DOCUMENT PAYMENT. D. MEDICAL REPORTS TO JUSTIFY PRESENT DISABILITY. SETTLEMENTS: A. SIGNED PETITION, JUDGMENT, RECEIPT AND RELEASE, ORDER FROM OWCA, AND A C OPY OF THE CHECK OR COMPUTER PRINTOUT. B. SETTLEMENTS FOR AN ACCIDENT OCCURRING ON OR AFTER OCTOBER 1, 1995 AND AP PROVED BY THE LA. W. C. SIB, THE EMPLOYER/ SELF-INSURED OR INSURER MUST OBTAIN PRIOR WRITT EN APPROVAL FROM THE BOARD OF ANY LUMP SUM OR COMPROMISE SETTLEMENTS. QUESTIONS: HAS ANY SUBROGATION ACTION BEEN TAKEN OR DO YOU INTEND TO TAKE ANY ACTIO N TO RECOVER ALL OR PART OF THE COMPENSATION PAID TO THE EMPLOYEE? IF YES EXPLAIN_______YES _______NO ************************************************************************ ****************************** I HEREBY CERTIFY THAT AS OF THIS DATE, THE AFOREMENTIONED INFORMATION IS CORRECT AND ACCURATE TO THE BEST OF MY KNOWLEDGE. _________________________________ ________________________________ ______________________________ INSURANCE CARRIER SIGNATURE TITLE _________________________________ ________________________________ PHONE # DATE SIB Form B