Louisiana Request For Compromise Or Lump Sum Settlement
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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

Social Security No.
Date of Injury/Illness
Part(s) of Body Injured
OWC Docket Number
OWC District Number

-

-

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

State

Zip

State

Phone

Zip

Phone

EMPLOYER

INSURER/ADMINISTRATOR
(circle one)
9. Name

8. 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
State

Zip

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: