Transcription of Workers' Compensation - Stop Payment Form …
1 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 Benefits_____TOTAL INDEMNITY BENEFITS$_____TOTAL REHABILITATION EXPENSES$_____(Add A.)
2 Items 1-6)(Add D. Items 1-5) SETTLEMENT AMOUNT$ FUNERAL EXPENSES$ and Medical MEDICAL EXPENSES$_____TOTAL LEGAL EXPENSES$_____(Add C. Items 1-8)(Add F. Items 1-6) PARTY RECOVERY FOR COSTS$_____(Not Included Above) WORKERS Compensation COSTS$_____(Add A-G) OF UNUSED RESERVES$_____Submitted by:Preparer s Name: _____Employee Name: _____Employer/Insurer: _____Employer: _____Address: _____Address: _____Phone: ( ) _____Phone: ( ) _____Employer/Insurer NCCI Number:_____LWC-WC-1003 REV. 07/08
