Page 1 of 2 LWC-WC-1150 Revised 8/1/17 WORKERS222 COMPENSATION RECORDS REQUEST FORM Mail completed form to: Louisiana Workforce Commission Status of your records request: (Office use only.) OWCA Records Management Section Will be processed. 1001 N. 23rd Street Is being returned. See Section III, Page 2. P.O Box 94040 Has been processed. You owe a copying fee, Baton Rouge, LA 70804-9040 See Section III, Page 2. Telephone No.: 225-342-7565 Is complete. See Section III, Page 2. Note: Copies of documents provided through this request shall adhere to the provisions of La. R.S. 23:1020.1, et seq. and La. R.S. 44:1, et seq., which limits the inspection and copying of workers222 compensation records. *A $25.00 fee is required per employee search. (Exception: Requests for LWC-WC-1002 will NOT be assessed a $25.00 search fee.) Copying fees are $0.25 per page. Make all checks payable to the OWCA Administrative Fund. SECTION I: TO BE COMPLETED BY REQUESTOR 1. Select all that apply: I am the Employee OR Legal Representative of the Employee. (Attach letter of representation.) I am the Employer/Insurer OR Legal Representative of the Employer/Insurer. (Attach letter of representation.) I am NOT a party to a workers222 compensation claim. (Attach employee authorization, LWC-WC-1151.) I am a Prospective Employer. (Attach employee authorization, LWC-WC-1151.) 2. Name of Requestor (Please Print) 3. Phone Number 4. Company Name (If Applicable) 5. Fax Number 6. Address, City, State ZIP 7. Email SECTION II: RECORDS REQUESTED 1. Employee222s Name ( Please use a separate form for each employee .) 2. Employee222s Social Security Number 3. Identify the workers222 compensation claim you are requesting : Workers222 Compensation Claim Docket # Date of Injury ALL cases for this injured worker. - If known, list the Docket # and Date of Injury for each claim in the Additional Comments Section, see right. You will be assessed a $25.00 search fee for each workers222 compensation docket number. Additional C omments: 4. Additional records I am requesting: Notice Of Payment, Modification, Suspension, Termination or Controversion of Compensation or Medical Benefits (LWC-WC-1002). *Only available to Employee or Employee Representative per La. R.S. 23:1201.1. You will NOT be assessed a $25.00 search fee for this records request. Other documents requested. Please specify in the Additional Comments section. 5. Need records certified? (If ce rtified, you will be assessed $25 .00.) Yes No American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 LWC-WC-1150 Revised 8/1/17 I have read and understand this form and the accompanying instructions. I certify that all information provided by me to the Office of Workers222 Compensation Administration is accurate and correct to the best of my knowledge. I understand that providing false or misleading information may subject me to prosecution. Signature of Requestor Date SECTION III: TO BE COMPLETED BY OWCA RECORDS MANAGEMENT SECTION 1. This records request will NOT be processed due to the following: $25.00 Search fee not received. No Social Security Number/incomplete number. Employee Authorization form required. Incomplete information. Please provide: *Your request will NOT be processed until the information is provided. 2. Your request has been processed. Pages of responsive records have been found. Please submit a check in the amount of $ to the OWCA Administrative Fund. *No records will be sent until the check is received by the OWCA. Your request has produced more than one employee claim. claims have been found. Please submit a check in the amount of $ to the OWCA Administrative Fund. *No records will be sent until the check is received by the OWCA. 3. Your request is complete. The records search has: No Records Found See Attached records. Records request completed by Date: American LegalNet, Inc. www.FormsWorkFlow.com