Louisiana Employer Report of Injury Or Illness
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MAIL TO:
WORKERS' COMPENSATION INSURER

Employee Social Security Number
Employer UI Account Number

EMPLOYER REPORT
Employer Federal ID Number
OF
INJURY/ILLNESS
This report is completed by the Employer for each injury/illness identified by them or their employee as occupational. A copy
is to be provided to the employee and the insurer immediately.

PURPOSE OF REPORT: (Check all that apply)
__ More than 7 days of disability
__ Possible dispute
__ Injury resulted in death
__ Lump Sum Compromise/Settlement
__ Amputation or disfigurement
__ Other
1.Date ofReport
MM/DD/YY

2. Date / time of Injury
MM/DD/YY Time
__AM
__PM

6. If Fatal Injury, Give Date of
Death MM/DD/YY

3. Normal Starting Time Day
of Accident
__ AM
__ PM

7. Date Employer Knew of
Injury MM/DD/YY

10. Employee Name First

Middle

4. If Back toWork Give date
MM/DD/YY

5. At same wage?
__Yes __ No

8. Date Disability
began MM/DD/YY

Last

11. __ Male
__ Female

13. Address and Zip Code

15. Date of Hire

16. Date of Birth

19.