An Equal Opportunity Employer Program. Auxiliary aids and services are available upon request to individuals with disabilities. 1-800-259-5154 (TDD)
www.laworks.net
Notice shall be given by
delivering it or sending it
by certifi ed mail or return
receipt requested to:
Employer Representative
____________________________
____________________________
____________________________
____________________________
Employer
____________________________
____________________________
____________________________
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R.S. 23:1302 states that this
notice should be posted in a
convenient and conspicuous
place in the employer’s place of
business.
Revised May 2003
Reporting Injury
You should report to your employer any occupational disease or
personal injury that is work-related, even if you deem it to be minor.
Occupational Disease or Death
In case of an occupational disease, all claims are barred unless the
employee fi les a claim with his/her employer within one year of the
date that:
1 the disease manifests itself.
2 the employee is disabled as a result of the disease.
3 the employee knows or has reasonable grounds to believe that the
disease is occupationally related.
In case of death arising from an occupational disease, all claims
are barred unless the dependent(s) fi le a claim with the deceased
employee’s employer within one year of:
1 the date of death.
2 the date the claimant has reasonable grounds to believe that the
death resulted from occupational disease.
Filing Notice
In case of injury or death caused by a work-related accident, an injured
employee or any person claiming to be entitled to compensation either
as a claimant or as a representative of a person claiming to be entitled
to compensation, must give notice to the employer within 30 days of
the injury. If notice is not given within 30 days, no payments will be
made for such injury or death. In addition, any fraudulent action by the
employer, employee, or any other person for the purpose of obtaining
or defeating any benefi t or payment of workers’ compensation shall
subject such person to criminal as well as civil liabilities.
The above mentioned notice should be fi led with the employer at the
address shown to the right.
A notice so given shall not be held invalid because of any inaccuracy in
stating the time, place, nature or cause of injury, or otherwise, unless
it is shown that the employer was in fact misled to his detriment
thereby. Failure to give notice may not harm the employee if the
employer knew of the accident or if the employer was not prejudiced
by the delay or failure to give notice.
Physicians
In the event you are injured, you are entitled to select a physician
of your choice for treatment. The employer may choose another
physician and arrange an examination which you would be required to
attend.
Formal Claim
In order to preserve your right to benefi ts under the Louisiana
Workers’ Compensation Law, you must fi le a formal claim with the
Offi ce of Workers’ Compensation Administration within one year after
the accident if payments have not been made or within one year after
the last payment of weekly benefi ts.
Information
If you desire any information regarding your rights and entitlement to
benefi ts as prescribed by law, you may call or write to the Offi ce of
Workers’ Compensation Administration, Post Offi ce Box 94040, Baton
Rouge, Louisiana 70804-9040 or telephone (225) 342-7555.
Name and Address of Insurance Company
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Workers’ Compensation
