Transcription of LOUISIANA WORKERS’ COMPENSATION SECOND …
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LOUISIANA WORKERS’ COMPENSATION SECOND …
PAGE _____ OF _____ SIB FORM D (10/17) LOUISIANA WORKERS COMPENSATION SECOND injury BOARD POST HIRE/CONDITIONAL JOB OFFER KNOWLEDGE QUESTIONNAIRE EMPLOYEE: The intent of this questionnaire is to provide your employer with knowledge about any pre existing medical condition or disability which may entitle your employer to reimbursement from the LOUISIANA Workers COMPENSATION SECOND injury Board in the event you suffer an on the job This reimbursement in no way affects the benefits owed to you by your employer or its insurance company under the LOUISIANA Workers COMPENSATION Act.
page _____ of_____ sib form d (10/17) louisiana workers’ compensation second injury board post‐hire/conditional job offer knowledge questionnaire
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