Louisiana Disputed Claim For CompensationLouisiana Disputed Claim For Compensation
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Mail To:

1.

Social Security No.

2.

Date of Injury/Illness

3.

Part(s) of Body Injured

4.

Date of This Request

5.

Date of Hire

6.

Date of Birth

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LOCAL DISTRICT OFFICE
OR

OFFICE OF WORKERS' COMPENSATION
POST OFFICE BOX 94040
BATON ROUGE, LA 70804-9040
For information call (225) 342-7565
or Toll Free (800) 201-3457.

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Docket Number

DISPUTED CLAIM FOR COMPENSATION
7. This claim is submitted by:
__ Employee
__ Employer

__ Insurer

__ Dependent

__ Health Care Provider

__ LWC

__ Other

GENERAL INFORMATION
Claimant files this dispute with the Office of Workers' Compensation. This office must be notified immediately in writing of changes
in address. An employee may be represented by an attorney, but it is not required.

EMPLOYEE
8.

EMPLOYEE'S ATTORNEY
9. Name

Name
Street or Box

Street or Box

City

City
Zip

State
Phone (

State

)

Phone (

Zip
)

EMPLOYER