La. Admin. Code tit. 40 § I-105

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-105 - Forms

A. The following forms are prescribed for use as required by the Workers' Compensation Act and these rules.

1. Form LDOL-WC-1007, Employer's Report of Occupational Injury or Disease, shall be filed with the Office of Workers' Compensation and with the employer's insurer when required by R.S. 23:1306, or within seven days of the first mediation conference of a disputed claim for benefits, whichever comes first. Failure to file this form as required may be penalized pursuant to LAC 40:I.109.

2. Form LDOL-WC-1020, Employee's Monthly Report of Earnings, shall be filed with the employer's insurer by employees who receive workers' compensation indemnity disability benefits within 30 days of their job-related injury, and every 30 days thereafter as long as they receive workers' compensation indemnity disability benefits. This form does not have to be filed by employees who only have received medical benefits. Failure to file this form as required may result in a suspension of benefits.

3. Form LDOL-WC-1025

a. Form LDOL-WC-1025, Employee and Employer Certificate of Compliance, shall be filed with the employer's insurer after Form LDOL-WC-1007 has been filed with the Office of Workers' Compensation. Employers who fail to file this form as required are subject to a penalty of $500, payable to the insurer.

b. Form LDOL-WC-1025, Employee and Employer Certificate of Compliance, shall be filed with the employer's insurer by employees within 14 days of their receipt of the form, after Form LDOL-WC-1007 has been filed with the Office of Workers' Compensation. Employees who fail to file this form as required may have their benefits suspended; after this form is filed, employees are entitled to all suspended benefits, if otherwise eligible for benefits.

4. Form LDOL-WC-1026, Employee's Quarterly Report of Earnings, shall be filed with the employer's insurer by employees within 14 days of receipt of the form. This form does not have to be filed by employees who only have received medical benefits, or by employees who have timely filed all necessary LDOL-WC-1020 Forms. Employees who fail to file this form as required may have their benefits suspended; after this form is filed, employees are entitled to all suspended benefits, if otherwise eligible for benefits.

5. Form LDOL-WC-1017A

a. Form LDOL-WC-1017A, Employer's Report of Occupational Injury and Illness Quarterly Summary, shall be filed with the Office of Workers' Compensation by the last day of the first month of the succeeding quarter by all employers with 11 or more employees at any one time in the prior calendar year.

b. The following employers are exempt from the requirements of §105. A.5.a [also identified by their Standard Industrial Classification Codes (SIC Codes)]:

i.	agricultural production (SIC 01);
ii.	agricultural services (SIC 07);
iii.	automotive dealers and gasoline service stations (SIC 55);
iv.	apparel and accessory stores (SIC 56);
v.	furniture, home furnishings, and equipment stores (SIC 57);
vi.	eating and drinking places (SIC 58);
vii.	miscellaneous retail (SIC 59);
viii.	banking (SIC 60);
ix.	credit agencies other than banks (SIC 61);
x.	security, commodity brokers, and services (SIC 62);
xi.	insurance (SIC 63);
xii.	insurance agents, brokers, and services (SIC 64);
xiii.	real estate (SIC 65);
xiv.	holding and other investment offices (SIC 67);
xv.	personal services (SIC 72);
xvi.	business services (SIC 73);
xvii.	motion pictures (SIC 78);
xviii.	legal services (SIC 81);
xix.	educational services (SIC 82);
xx.	social services (SIC 83);
xxi.	museums, botanical, and zoological gardens (SIC 84);
xxii.	membership organizations (SIC 86);
xxiii.	engineering, accounting, research and management (SIC 87);
xxiv.	private households (SIC 88);
xxv.	miscellaneous services (SIC 89);
xxvi.	offices and clinics of doctors of medicine (SIC 8011);
xxvii.	offices and clinics of dentists (SIC 8021);
xxviii.	offices and clinics of doctors of osteopathy (SIC 8031);
xxix.	offices and clinics of chiropractors (SIC 8041);
xxx.	offices and clinics of optometrists (SIC 8042);
xxxi.	offices and clinics of podiatrists (SIC 8043);
xxxii.	offices and clinics of health practitioners, not elsewhere classified (SIC 8049);
xxxiii.	medical laboratories (SIC 8071);
xxxiv.	dental laboratories (SIC 8072);
xxxv.	home health care services (SIC 8082);
xxxvi.	kidney dialysis centers (SIC 8092);
xxxvii.	specialty outpatient facilities, not elsewhere classified (SIC 8093);
xxxvii.	health and allied services, not elsewhere classified (SIC 8099)

c. Failure to file this form as required may be penalized pursuant to LAC 40:I.109.

La. Admin. Code tit. 40, § I-105

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 11:776 (August 1985), amended by the Department of Employment and Training, LR 17:358 (April 1991), amended by the Department of Labor, Office of Workers' Compensation, LR 22:221 (March 1996), LR 22:992 (October 1996).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1021.