Form LWC-WC IA-1 "Workers Compensation - First Report of Injury or Illness" - Louisiana

What Is Form LWC-WC IA-1?

This is a legal form that was released by the Louisiana Workforce Commission - a government authority operating within Louisiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2002;
  • The latest edition provided by the Louisiana Workforce Commission;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LWC-WC IA-1 by clicking the link below or browse more documents and templates provided by the Louisiana Workforce Commission.

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Download Form LWC-WC IA-1 "Workers Compensation - First Report of Injury or Illness" - Louisiana

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WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS
EMPLOYER (NAME & ADDRESS INCL ZIP)
CARRIER/ADMINISTRATOR CLAIM NUMBER
OSHA LOG NUMBER
REPORT PURPOSE CODE
JURISDICTION
JURISDICTION CLAIM NUMBER
INSURED REPORT NUMBER
EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT)
LOCATION #
INDUSTRY CODE
EMPLOYER FEIN
PHONE #
CARRIER/CLAIMS ADMINISTRATOR
CARRIER (NAME, ADDRESS, & PHONE #)
POLICY PERIOD
CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)
TO
CHECK IF APPROPRIATE
SELF INSURANCE
CARRIER FEIN
POLICY/SELF-INSURED NUMBER
ADMINISTRATOR FEIN
AGENT NAME & CODE NUMBER
EMPLOYEE/WAGE
NAME (LAST, FIRST, MIDDLE)
DATE OF BIRTH
SOCIAL SECURITY NUMBER
DATE HIRED
STATE OF HIRE
ADDRESS (INCL ZIP)
SEX
MARITAL STATUS
OCCUPATION/JOB TITLE
UNMARRIED
M
MALE
U
EMPLOYMENT STATUS
SINGLE/DIVORCED
F
FEMALE
M
MARRIED
UNKNOWN
U
S
SEPARATED
PHONE
NCCI CLASS CODE
# OF DEPENDENTS
K
UNKNOWN
RATE
DAY
MONTH
DAYS WORKED/WEEK
FULL PAY FOR DAY OF INJURY?
YES
NO
PER:
WEEK
OTHER:
DID SALARY CONTINUE?
NO
YES
OCCURRENCE/TREATMENT
TIME EMPLOYEE
AM
DATE OF INJURY/ILLNESS
TIME OF OCCURRENCE
AM
LAST WORK DATE
DATE EMPLOYER
DATE DISABILITY
BEGAN WORK
NOTIFIED
BEGAN
PM
( ) CANNOT BE
PM
DETERMINED
CONTACT NAME/PHONE NUMBER
TYPE OF INJURY/ILLNESS
PART OF BODY AFFECTED
DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER’S
TYPE OF INJURY/ILLNESS CODE
PART OF BODY AFFECTED CODE
PREMISES?
YES
NO
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE
ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS
OCCURRED
EXPOSURE OCCURRED
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE
ILLNESS EXPOSURE OCCURRED
OCCURRED
HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED
THE EMPLOYEE OR MADE THE EMPLOYEE ILL
CAUSE OF INJURY CODE
DATE RETURN(ED) TO WORK
IF FATAL, GIVE DATE OF DEATH
WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?
YES
NO
NO
WERE THEY USED?
YES
PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)
HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS)
INITIAL TREATMENT
0
NO MEDICAL TREATMENT
1
MINOR: BY EMPLOYER
2
MINOR CLINIC/HOSP
EMERGENCY CARE
3
4
HOSPITALIZED > 24 HOURS
FUTURE MAJOR MEDICAL/
5
LOST TIME ANTICIPATED
OTHER
WITNESSES (NAME & PHONE #)
DATE ADMINISTRATOR NOTIFIED
DATE PREPARED
PREPARER’S NAME & TITLE
PHONE NUMBER
IAIABC 2002
LWC-WC IA-1
WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS
EMPLOYER (NAME & ADDRESS INCL ZIP)
CARRIER/ADMINISTRATOR CLAIM NUMBER
OSHA LOG NUMBER
REPORT PURPOSE CODE
JURISDICTION
JURISDICTION CLAIM NUMBER
INSURED REPORT NUMBER
EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT)
LOCATION #
INDUSTRY CODE
EMPLOYER FEIN
PHONE #
CARRIER/CLAIMS ADMINISTRATOR
CARRIER (NAME, ADDRESS, & PHONE #)
POLICY PERIOD
CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)
TO
CHECK IF APPROPRIATE
SELF INSURANCE
CARRIER FEIN
POLICY/SELF-INSURED NUMBER
ADMINISTRATOR FEIN
AGENT NAME & CODE NUMBER
EMPLOYEE/WAGE
NAME (LAST, FIRST, MIDDLE)
DATE OF BIRTH
SOCIAL SECURITY NUMBER
DATE HIRED
STATE OF HIRE
ADDRESS (INCL ZIP)
SEX
MARITAL STATUS
OCCUPATION/JOB TITLE
UNMARRIED
M
MALE
U
EMPLOYMENT STATUS
SINGLE/DIVORCED
F
FEMALE
M
MARRIED
UNKNOWN
U
S
SEPARATED
PHONE
NCCI CLASS CODE
# OF DEPENDENTS
K
UNKNOWN
RATE
DAY
MONTH
DAYS WORKED/WEEK
FULL PAY FOR DAY OF INJURY?
YES
NO
PER:
WEEK
OTHER:
DID SALARY CONTINUE?
NO
YES
OCCURRENCE/TREATMENT
TIME EMPLOYEE
AM
DATE OF INJURY/ILLNESS
TIME OF OCCURRENCE
AM
LAST WORK DATE
DATE EMPLOYER
DATE DISABILITY
BEGAN WORK
NOTIFIED
BEGAN
PM
( ) CANNOT BE
PM
DETERMINED
CONTACT NAME/PHONE NUMBER
TYPE OF INJURY/ILLNESS
PART OF BODY AFFECTED
DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER’S
TYPE OF INJURY/ILLNESS CODE
PART OF BODY AFFECTED CODE
PREMISES?
YES
NO
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE
ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS
OCCURRED
EXPOSURE OCCURRED
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE
ILLNESS EXPOSURE OCCURRED
OCCURRED
HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED
THE EMPLOYEE OR MADE THE EMPLOYEE ILL
CAUSE OF INJURY CODE
DATE RETURN(ED) TO WORK
IF FATAL, GIVE DATE OF DEATH
WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?
YES
NO
NO
WERE THEY USED?
YES
PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)
HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS)
INITIAL TREATMENT
0
NO MEDICAL TREATMENT
1
MINOR: BY EMPLOYER
2
MINOR CLINIC/HOSP
EMERGENCY CARE
3
4
HOSPITALIZED > 24 HOURS
FUTURE MAJOR MEDICAL/
5
LOST TIME ANTICIPATED
OTHER
WITNESSES (NAME & PHONE #)
DATE ADMINISTRATOR NOTIFIED
DATE PREPARED
PREPARER’S NAME & TITLE
PHONE NUMBER
IAIABC 2002
LWC-WC IA-1
EMPLOYER’S INSTRUCTIONS
DO NOT ENTER DATA IN SHADED FIELDS
DATES:
Enter all dates in MM/DD/YY format.
INDUSTRY CODE:
This is the code which represents the nature of the employer’s business, which is contained in the Standard
Industrial Classification Manual or the North American Industry Classification System, published by the
Federal Office of Management and Budget.
CARRIER:
The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf
of the employer of the claimant.
CLAIMS ADMINISTRATOR:
Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for
administering the claim.
AGENT NAME & CODE NUMBER:
Enter the name of your insurance agent and his/her code number if known. This information can be found on
your insurance policy.
OCCUPATION/JOB TITLE:
This is the primary occupation of the claimant at the time of the accident or exposure.
EMPLOYMENT STATUS:
Indicate the employee’s work status. The valid choices are:
Full-Time
On Strike
Unknown
Volunteer
Part-Time
Disabled
Apprenticeship Full-Time
Seasonal
Not Employed
Retired
Apprenticeship Part-Time
Piece Worker
DATE DISABILITY BEGAN:
The first day on which the claimant originally lost time from work due to the occupation injury or
disease or as otherwise designated by statute.
CONTACT NAME/PHONE NUMBER:
Enter the name of the individual at the employer’s premises to be contacted for additional information.
TYPE OF INJURY/ILLNESS:
Briefly describe the nature of the injury or illness, (eg. Lacerations to the forearm).
PART OF BODY AFFECTED:
Indicate the part of body affected by the injury/illness, (eg. Right forearm, lower back).
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (eg.
Maintenance Department or Client’s office at 452 Monroe St., Washington, DC 26210)
If the accident or illness exposure did not occur on the employer’s premises, enter address or
location. Be specific.
LWC-WC IA-1
IAIABC 2002
EMPLOYER’S INSTRUCTIONS – cont’d
ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR
ILLNESS EXPOSURE OCCURRED:
(eg. Acetylene cutting torch, metal plate)
List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or
operating when the injury or illness occurred. Be specific, for example: decorator’s scaffolding, electric
sander, paintbrush, and paint.
Enter “NA” for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed
do not have to be directly involved in the employee’s injury or illness.
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE
OCCURRED:
(eg. Cutting metal plate for flooring)
Describe the specific activity the employee was engaged in when the accident or illness exposure
occurred, such as sanding ceiling woodwork in preparation for painting.
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
Describe the work process the employee was engaged in when the accident or illness exposure occurred, such
as building maintenance. Enter “NA” for not applicable if employee was not engaged in a work process (eg.
walking along a hallway).
HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF
EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE
THE EMPLOYEE ILL:
(Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against
the hot metal.)
Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and
name any objects or substance that directly injured the employee or made the employee ill. For example:
Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The
worker’s right wrist was broken in the fall.
DATE RETURN(ED) TO WORK:
Enter the date following to most recent disability period on which the employee returned to work.
LWC-WC IA-1
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