La. Admin. Code tit. 40 § III-101
Current through Register Vol. 50, No. 11, November 20, 2024
Section III-101 - Approval of Settlements; Requirements ; Computation of TimeA.1. Requests for approval of the settlement of a third-party claim for settlement amounts less than $50,000 shall be submitted by facsimile transmission or hand delivery to the offices of the Second Injury Board.2. Requests for approval of all other settlements may be submitted by United States Postal Services, facsimile transmission or hand delivery to the offices of the Second Injury Board.B. Requests for approval of the settlement of a third-party claim shall be submitted on SIB Form C.C. In computing the period of time allowed for response by the Second Injury Board to a request for settlement authority, the date of submission of the request shall not be included. The last day of the period shall not be included, unless it is a legal holiday, in which event the period shall run until the end of the next day which is not a legal holiday. The board shall have three working days, excluding legal holidays, to respond to the request.D. SIB Form C Second Injury Board
Request for Settlement Authority
Third-Party Claims Less Than $50,000
R.S. 23:1378(A)(8)(a)(iii)
All requests must be in writing .
All requests must be faxed to 225-219-5968 or hand delivered to the Second Injury Fund.
All questions must be answered and submitted with required attachments.
Name of Injured Worker : |
Name of Workers' Compensation Insurance Carrier and/or Self-Insured Employer: |
SIB Claim No : |
Weekly Compensation Rate : |
What is the total paid to date by the workers' compensation insurance carrier and/or self-insured employer?
a. Indemnity ________________b. Medical ________________ What is the third party offer to:
a. The workers' compensation insurance carrier and or self-insured employer? ________________b. The injured worker? ________________c. Others (specify)? ________________ Does the workers' compensation insurance carrier and/or self-insured employer anticipate waiving recovery of any portion of the amount paid to the injured worker? | []Yes* [] No *If yes, what amount or percentage will be waived? ______________________ |
In addition to the above responses, the following must be attached:
A recent medical report documenting current medical condition.
A completed settlement evaluation form.
Not required but recommended :
Any additional information you care to submit to support your position.
SIB Form C
La. Admin. Code tit. 40, § III-101
Promulgated by the Department of Labor, Office of Workers' Compensation, Second Injury Board, LR 1:145 (February 1975), amended LR 3:48 (January 1977), LR 3:497 (December 1977), amended by the Department of Employment and Training, Office of Workers' Compensation, Second Injury Board, LR 17:179 (February 1991), amended by Department of Labor, Office of Workers' Compensation, Second Injury Board, LR 32:92 (January 2006).AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1378(A)(8)(a)(v).