LAC 40:I.105 – Forms

A. The following forms are prescribed for use as required by the Workers' Compensation Act and these rules.
1. 1. Form LW-WC-IA-1, Employer's First Report of Injury or Illness, shall be filed with the employer's insurer when required by R.S. 23:1306. Failure to file this form as required may be penalized pursuant to LAC 40:I.109.
2. 2. Form LW-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. 3. Form LW-WC-1025
  1. a. Form LW-WC-1025.ER, Employer Certificate of Compliance, shall be filed with the employer's insurer after Form LW-WC-IA-1 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.
  2. b. Form LW-WC-1025.EE, Employee Certificate of Compliance, shall be filed with the employer's insurer by employees within 14 days of their receipt of the form, after Form LW-WC-IA-1 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.

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1291.

Historical Note

HISTORICAL NOTE: 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), amended by the Louisiana Works, Office of Workers' Compensation Administration, LR 52:499 (April 2026).