Louisiana Required Postings and Forms
Please post the following notices, both in English and Spanish, in a conspicuous location frequented by employees such as the break room, lunch room or time clock. If you have multiple office locations be sure to post the notices at each location.
The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
- Form LWC-WC-IA-1 First Report of Injury (FROI). As soon as you have been notified of a work-related injury, please fill out this form and submit it to EMPLOYERS. This form must be completed within three days from notice of a work-related injury. Fatalities must be reported within 24 hours. Please use this form to notify EMPLOYERS of every work-related injury or disease suffered by an employee, regardless of severity.
- Wage Statement. This form enables us to calculate the correct compensation that may be due your injured employee. Please complete the form and submit it to EMPLOYERS within five days after your knowledge of any accident that has caused your employee to be disabled for more than seven scheduled calendar work days.
- First Fill Form. This form provides your employees with basic information about our Pharmacy Benefit Program, including such things as the phone number to call to locate a First Fill participating pharmacy. When your employee becomes injured, please print and complete this form and provide it to your injured employee. Your employee will need to provide this completed form along with the prescription for his/her work-related injury or occupational disease to the pharmacist. Using this form will help enable quick authorization for your employee’s initial medication and ensure that the initial prescription is provided at no cost to the injured employee.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 32036, Lakeland, FL 33802-2036. You should also keep a copy on file for your records.
- Second Injury Board Questionnaire – This questionnaire is to be completed by an employee. It is used to provide their employer with knowledge about any pre‐existing medical condition or disability which may entitle the employer to reimbursement from the Louisiana Workers’ Compensation Second Injury Board should an on‐the‐job injury be suffered.
More Louisiana Workers’ Comp Resources
- Off-Site Transitional Duty Program – Helping Your Injured Employees Get Back to Work. A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.