Transcription of Workers' Compensation - Stop Payment Form …
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Workers' Compensation - Stop Payment Form …
MAIL TO:OFFICE OF WORKERS COMPENSATION_____-_____-_____ POST OFFICE BOX 94040 SOCIAL SECURITY NUMBER BATON ROUGE, LA 70804-9094(225) 342-7565, TOLL FREE (800) 201-3457 _____ DATE OF INJURY/ILLNESSSTOP Payment FORMThis form is sent by the Employer/Insurer to the injured workers and the OWCA within 30 days of the closure of a AMENDED COPY is required if the case re-opens or additional costs are (Employee)(Date of Birth)Date of this (s) of Body Injured Date Compensation Paid Through1. Purpose of form : (check one)_ Payment stopped-Employee working at equal or greater wages _ Payment stopped-Maximum period for paying SEB has expired_ Payment stopped-Employee able to work at same or greater wages _ Payment stopped-3rd Party recovery without notice_ Payment stopped-Lump sum/Compromise settlement approved _ Amend or correct prior 1003_ of ICD - 9 Diagnostic code(s) CPT Procedure code(s) INCURRED FOR THIS Rehabilitation Rehabilitation Market Survey
Title: Workers' Compensation - Stop Payment Form (Form LDOL-WC-1003) Author: Kayef Subject: Form mailed to OWCA within 30 days of the closure of the claim.
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