MAIL TO: - -
WORKERS' COMPENSATION INSURER Employee Social Security Number
Employer UI Account Number
EMPLOYER REPORT Employer Federal ID Number
OF
INJURY/ILLNESS
This report is completed by the Employer for each injury/illness identified by them or their employee as occupational. A copy
is to be provided to the employee and the insurer immediately.
PURPOSE OF REPORT: (Check all that apply)
__ More than 7 days of disability __ Possible dispute __ Medical only
__ Injury resulted in death __ Lump Sum Compromise/Settlement ( DO NOT mail copy to OWCA )
__ Amputation or disfigurement __ Other
1.Date ofReport
MM/DD/YY
2. Date / time of Injury
MM/DD/YY Time
__AM
__PM
3. Normal Starting Time Day
of Accident
__ AM
__ PM
4. If Back toWork -
Give date
MM/DD/YY
5. At same wage?
__Yes __ No
DO NOT WRITE
IN THIS
COLUMN
6. If Fatal Injury, Give Date of
Death MM/DD/YY
7. Date Employer Knew of
Injury MM/DD/YY
8. Date Disability
began MM/DD/YY
9. Last Full Day Paid
MM/DD/YY
Date Received
10. Employee Name First Middle Last 11. __ Male
__ Female
12. Employee Phone #
( )
Naics:.
13. Address and Zip Code 14. Parish of Injury State-Parish
15. Date of Hire 16. Date of Birth 17. Occupation 18. Dept/Division Employed Occupation
19. Place of Injury-Employer's
Premises ? __ Yes __ No
20. If No, Indicate Location-Street, City, Parish and State Nature
21. What work activity was the employee doing when the injury occurred? (Give weight, size and shape of materials or equipment involved). Explain what
employee was doing with them. Indicate if correct procedures were followed.
Part of Body
Source
Event
NCCI
22. What caused injury to happen? (Describe fully the events which resulted in injury or disease. Explain what happened and how it happened. Name any objects or substances involved and explain how they were
involved. Give full details on all factors which led to or contributed to this injury or illness.)
23. Part of Body Injured and Nature of Injury or Illness (ex. left leg; multiple fractures) 24. If Occ. Disease-Give Date
Diagnosed
25. Physician and Address 26. If Hospitalized, give name & address of facility
27. Employer's Name 28. Person Completing This Report - Please print
29. Employer's Address and Zip Code 30. Employer's Telephone Number
( )
31. Employer's Mailing Address-If Different From Above 32. Nature of Business-Type of Mfg., Trade, Construction, Service, etc.
33. Wage Information (optional) Employee was paid __ Daily __ Weekly __ Monthly __ Other. T he average weekly wage was $ per week.
LDOL-WC-1007 Insurer Name: Insurer's Administrator or Representative:
Rev: 08/06 Phone: Phone:
Download Employer’s Certificate of Compliance
Address: Address:
