ࡱ> 7 4bjbjUU 7|7|vl DL "Xd(d(d(d(O)^. 1eKgKgKgKgKgKgK$M PKA3K)O)A3A3KAd(d(LAAAA3d(d(eKAA3eKAAGGd(" @I 6tGGdL0LGPO<PGAOFFICE OF WORKER S COMPENSATION POST OFFICE BOX 94040 BATON ROUGE, LA 70804-9040 (225) 342-7565 EMPLOYER REPORT OF INJURY / ILLNESS LDOL-WC-1007Employee Social Security Number  FORMTEXT      Employer UI Account Number  FORMTEXT      Employer Federal ID Number  FORMTEXT      Location Code  FORMTEXT      This report is completed by the Employer for each injury/illness identified by them or their employee as occupational. A copy is to be provided to the employee and the insurer immediately. Forms for cases resulting in more than 7 days of disability or death are to be sent to the OWCA by the 10th day after the Incident or as requested by the OWCA.   PURPOSE OF REPORT: (Check all that apply)  FORMCHECKBOX  More than 7 days of disability  FORMCHECKBOX  Injury resulted in death  FORMCHECKBOX  Amputation or disfigurement   FORMCHECKBOX  Possible dispute  FORMCHECKBOX  Lump Sum Compromise/Settlement  FORMCHECKBOX  Other  FORMCHECKBOX  Medical Only (no copy needed by OWCA)1. Date of Report MM/DD/YY  FORMTEXT      2. Date / time of injury: MM/DD/YY Time  FORMCHECKBOX  AM  FORMTEXT        FORMCHECKBOX  PM3. Normal Starting Time Day of Accident:  FORMCHECKBOX  AM  FORMTEXT        FORMCHECKBOX  PM4. If Back to Work Give Date MM/DD/YY  FORMTEXT      5. At same Wage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMTEXT      DO NOT WRITE IN THIS COLUMN6. If Fatal injury, Give Date of Death: MM/DD/YY  FORMTEXT      7. Date Employer Knew of injury: MM/DD/YY  FORMTEXT      8. Date Disability began: MM/DD/YY  FORMTEXT      9. Last Full Day Paid MM/DD/YY  FORMTEXT      Date Received 10. Employee Name: First  FORMTEXT       Middle  FORMTEXT       Last  FORMTEXT      11.  FORMCHECKBOX  Male  FORMCHECKBOX  Female 12. Employee Phone # ( FORMTEXT      )  FORMTEXT      - FORMTEXT      S.I.C. 13. Address and Zip Code  FORMTEXT         FORMTEXT        FORMTEXT        FORMTEXT      14. Parish of Injury  FORMTEXT      State-Parish 15. Date of Hire  FORMTEXT      16. Age at illness/injury  FORMTEXT      17. Occupation  FORMTEXT      18. Dept./Division Employed:  FORMTEXT      Occupation 19. Place of Injury-Employer s Premises ?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 20. If No, indicate Location-Street, City, Parish and State  FORMTEXT      Nature 21. What work activity was the employee doing when the incident occurred ? (Give weight, size and shape of material or equipment involved. Tell what he was doing with them. Indicate if correct procedures were followed.)  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Part of Body Source Event NCC: 22. What caused the incident to happen? (Describe fully the events which resulted in injury or disease. Tell what happened and how it happened. Name any objects or substances involved and tell how they were involved. Give full details on all factors which led to or contributed to this injury or illness.)  FORMTEXT        FORMTEXT        FORMTEXT      23. Part of body injured and Nature of Injury or Illness(ex. left leg: multiple fractures)  FORMTEXT        FORMTEXT      24. If Occ. Disease- Give Date Diagnosed  FORMTEXT        FORMTEXT      25. Physician and Address  FORMTEXT      street  FORMTEXT      city  FORMTEXT      state  FORMTEXT      zip  FORMTEXT      26. If Hospitalized, give name & address of facility  FORMTEXT      27. Employer s Name  FORMTEXT      28. Person Completing This Report  Please print  FORMTEXT      29. Employer s Address  FORMTEXT      street  FORMTEXT      city  FORMTEXT      state  FORMTEXT      zip  FORMTEXT      30. Employer s Telephone Number ( FORMTEXT      )  FORMTEXT       -  FORMTEXT      31. Employer s Mailing Address  If Different From Above  FORMTEXT      city  FORMTEXT      state  FORMTEXT      zip  FORMTEXT      32. Nature of Business  Type of Mfg., Trade, Construction, Service, etc.  FORMTEXT      33. Wage Information Employee was paid  FORMCHECKBOX  Daily  FORMCHECKBOX  Weekly  FORMCHECKBOX  Monthly  FORMCHECKBOX  Other The average weekly wage was $  FORMTEXT       per week. 34. Verification of Employer Knowledge of this Report. Name:  FORMTEXT       Title:  FORMTEXT       Date:  FORMTEXT       OFFICE OF RISK MANAGEMENT P.O. Box 91106 Baton Rouge, LA 70821-9106 Phone No. (225) 219-0168 DA 1973 R 8/98  OFFICE OF RISK MANAGEMENT COPY LDOL  WC  1025 ER R 8/98 EMPLOYER CERTIFICATE OF COMPLIANCE You must submit this Certification to your workers' compensation insurer. Failure to submit this Certification as required may result in your being penalized by a fine of $500, payable to your insurer. You must secure workers' compensation for your employees through insurance or by becoming an authorized self-insured. If you fail to provide security for workers' compensation, you must pay an additional 50% in weekly benefits to your injured workers. If you willfully fail to provide security for workers' compensation, then you are subject to a fine of up to $ 10,000, imprisonment with or without hard labor for not more than I year, or both. If you have been previously fined and again fail to provide security for workers' compensation, then you are subject to additional penalties, including a court order to cease and desist from continuing further business operations. You must not collect, demand, request, or accept any amount from any employee to pay or reimburse for the workers' compensation insurance premium. If you violate this provision, you may be punished with a fine of not more than $500, or imprisoned with or without hard labor for not more than one year, or both. It is unlawful for you to willfully make, or to assist or counsel someone else to make, a false statement or representation in order to obtain or to defeat workers' compensation benefits. If you violate this provision, you may be fined up to $10,000, imprisoned with or without hard labor for up to I 0 years, or both depending on the amount of benefits unlawfully obtained or defeated. In addition to these criminal penalties, you may be assessed a civil penalty of up to $5,000.  EMPLOYER CERTIFICATION I certify that I can read the English language, that I have read this entire document and understand its contents, and that I understand I am held responsible for this information. I certify my compliance with the Louisiana Workers' Compensation Act. Preparer Name (PRINT)  FORMTEXT      Signature Date  FORMTEXT      Company Name ( FORMTEXT      )  FORMTEXT       -  FORMTEXT      Company Address  FORMTEXT      Phone Number  FORMTEXT        FORMTEXT      Insurance Policy Number  FORMTEXT       -  FORMTEXT       -  FORMTEXT      Employee Name Employee Social Security Number  (jln68:Nȶ}pȶ[}pȶ(jvB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu(jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ"jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ5B*CJOJQJ\^JphsWQB*CJ OJQJ^JphsWQB*CJOJQJ^JphsWQ@l*jl $$Ifa$$If4ztkttt $$Ifa$$If$$Ifl4F *` ` 06 sTQ sWQ sTQ sWQ4 la68`bdfztktttztkttt $$Ifa$$If$$Ifl4F *   06 sTQ sWQ sTQ sWQ4 la NPR\^`7h$ % ٵَyٵeOeOeOe*5>*B*CJOJQJRHc\^JaJphsWQ'5B*CJOJQJRHc\^JaJphsWQ(j^B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQB*CJOJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu"jB*CJOJQJU^JphsWQ(jB*CJOJQJU^JphsWQhzgWQ$IfdJ$7$8$H$If$dJ$7$8$H$Ifa$$$Ifl4F *   06 sTQ sWQ sTQ sWQ4 la ! " $If^$$Ifl4*+064 la" # $ % O P $Ifq$$Ifl40*`&064 la% 8 O P Q _ ` a   ( * , j l n r](jB*CJOJQJU^JphsWQ(j.B*CJOJQJU^JphsWQ(jB*CJOJQJU^JphsWQ(jFB*CJOJQJU^JphsWQ(jB*CJOJQJU^JphsWQ"jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQB*CJOJQJ^JphsWQ$  l n  r$$Ifl4F ` ` 06     4 la$If n p R T V j l n x z ῲῲ~q\~E~-jB*CJOJQJU^JmHnHphsWQu(jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ"jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ(jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQ(jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ"jB*CJOJQJU^JphsWQ  @ R T | @ e_VV_____ $$Ifa$$If$$Ifl4Z\*      06sWQsWQsWQsTQ4 la z |    4 6 8 @ B V X Z d f ~ 2 4 6 R 埒}fQ(jZB*CJ OJQJU^JphsWQ-jB*CJOJQJU^JmHnHphsWQu(jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ"jB*CJOJQJU^JphsWQ(jrB*CJ OJQJU^JphsWQ"jB*CJ OJQJU^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQB*CJOJQJ^JphsWQ ^ :\  $$Ifa$ $$Ifa$$IfR T V ^ ` t v x (*,68:\^z̺l_̺J_(j.B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ(jB*CJ OJQJU^JphsWQ-jB*CJOJQJU^JmHnHphsWQu(jDB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ"jB*CJOJQJU^JphsWQB*CJ OJQJ^JphsWQ"jB*CJ OJQJU^JphsWQ(jB*CJ OJQJU^JphsWQz|~̷̥l\O:(j B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ5B*CJOJQJ\^JphsWQ-jB*CJOJQJU^JmHnHphsWQu(j B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ"jB*CJOJQJU^JphsWQ(j B*CJ OJQJU^JphsWQB*CJ OJQJ^JphsWQ"jB*CJ OJQJU^JphsWQ(jB*CJ OJQJU^JphsWQ\h$If$$Iflֈ * 6  <06sWQsWQsWQsWQsWQsTQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsTQsTQsWQsWQsWQsWQsWQsWQ4 la\>,$,.0:<(*ɼ֯ɼ֯ɼ֯pc֯B*CJOJQJ^JphsWQ(jf B*CJOJQJU^JphsWQ(j B*CJOJQJU^JphsWQ(jz B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQ"jB*CJOJQJU^JphsWQ-jB*CJOJQJU^JmHnHphsWQuLN|5X////$If$$Iflr*;  206sWQsWQsWQsTQsTQsWQsWQsWQsWQsWQsWQsWQsTQsTQsWQsWQsWQsWQsWQ4 la(*,68NPlnpٵٛٵٛqٵ_J__(j> B*CJ OJQJU^JphsWQ"jB*CJ OJQJU^JphsWQ(j B*CJOJQJU^JphsWQ(jR B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu"jB*CJOJQJU^JphsWQ(j B*CJOJQJU^JphsWQ:B|ftvx $If^ $If^$If,.0:<>@TVXbḓ̿ṱ_ṱJt̿(jB*CJOJQJU^JphsWQ(jB*CJOJQJU^JphsWQ-jB*CJOJQJU^JmHnHphsWQu(j*B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ"jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQ"jB*CJ OJQJU^JphsWQ(j B*CJ OJQJU^JphsWQxzX$If$$Iflֈ}5 r*=`  <06sWQsWQsWQsTQsTQsWQsWQsWQsWQsWQsWQsWQsWQsTQsWQsWQsWQsWQsWQ4 la.02Z\^ "$$If024HJLVX\^`tvxq\(jB*CJOJQJU^JphsWQ(jxB*CJOJQJU^JphsWQ(jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu(jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ"jB*CJOJQJU^JphsWQ"HJL`bdnp RTٵٛٵyٛdٵyٛOٵy(jB*CJOJQJU^JphsWQ(jPB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ(jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu"jB*CJOJQJU^JphsWQ(jdB*CJOJQJU^JphsWQ$&H$If$$Iflֈ r*^r`  <06sWQsWQsWQsWQsTQsWQsWQsWQsWQsWQsWQsWQsWQsTQsWQsWQsWQsWQ4 laHJrRT|$IfTVjlnxz$&BDFl_J(jB*CJOJQJU^JphsWQB*CJ OJQJ^JphsWQ(j(B*CJ OJQJU^JphsWQ(jB*CJ OJQJU^JphsWQ"jB*CJ OJQJU^JphsWQB*CJ OJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu(j<B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ"jB*CJOJQJU^JphsWQNP3----$If$$Ifl4r *   206sWQsWQsWQsTQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQ4 laa$$IflFP*8  06 sWQsWQsWQ sWQsWQsWQ sTQsTQsWQ sWQsWQsWQ4 la$If ,.0:<>@BVXZdӾxcN(jvB*CJOJQJU^JphsWQ(jB*CJOJQJU^JphsWQ(jB*CJOJQJU^JphsWQB*CJ OJQJ^JphsWQB*CJ OJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu(jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ"jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ>@hv($$Ifl4U0*`  06sTQsWQsWQsWQsWQsWQsWQ4 la$If df&(<>@JLNPRfhjtvxz|XZ\prt~ԿԆq\(jNB*CJOJQJU^JphsWQ(jB*CJOJQJU^JphsWQ(jbB*CJOJQJU^JphsWQB*CJ OJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu(jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQ"jB*CJOJQJU^JphsWQ$|$vvv$If$$Ifl4\0*   06sWQsWQsWQsWQsWQsWQ4 la| vvv$If$$Ifl490*   06sWQsWQsWQsWQsWQsWQ4 la&NPxz|vvvvvvv$If$$Ifl4.0*   06sWQsWQsWQsTQsTQsWQsWQ4 laZ&(P\$If]$$Ifl*+06sTQsWQsTQsWQ4 la "$&(*>@BLNٵ٨ٵ٨qٵd٨Oٵd(j&B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ(jB*CJOJQJU^JphsWQB*CJ OJQJ^JphsWQ(j:B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu"jB*CJOJQJU^JphsWQ(jB*CJOJQJU^JphsWQPR ( * R Z \ $Ifp$$Ifl0*1 06sTQsTQsWQsWQsWQsWQsWQsWQ4 la    ( * , @ B D N P Z \ ^ r t v !˴˧˴˧p˴˧[˴˧(jB*CJOJQJU^JphsWQ(jB*CJOJQJU^JphsWQ(jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu"jB*CJOJQJU^JphsWQ(jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ!\ !!B!=$$Iflֈ p*WD,06sWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQ4 la$If!! !!!@!B!D!X!Z!\!f!h!!!!!!!!!&"("*">"@"B"L"N"^"`"b"v"ٵٛٵٛqٵٛ\ٵٛ(jB*CJOJQJU^JphsWQ(j`B*CJOJQJU^JphsWQ(jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu"jB*CJOJQJU^JphsWQ(jtB*CJOJQJU^JphsWQ B!j!!!!&"("P"^"`"""""""p$$Ifl0p*,06sWQsWQsWQsWQsWQsWQsWQsWQ4 la$Ifv"x"z""""""""""""""""""""""### #"#d#f#h#j#~#ٵٛٵٛqٵٛ\ٵٛ(jB*CJOJQJU^JphsWQ(j8B*CJOJQJU^JphsWQ(jB*CJOJQJU^JphsWQB*CJOJQJ^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu"jB*CJOJQJU^JphsWQ(jLB*CJOJQJU^JphsWQ!""""$#d#f##$If~####################Z$\$^$r$t$v$$$$$$$ٵٵ٨ٵ~٨qٵ\٨qٵ(j!B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ(j!B*CJOJQJU^JphsWQ(j B*CJOJQJU^JphsWQB*CJ OJQJ^JphsWQB*CJOJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu"jB*CJOJQJU^JphsWQ(j$ B*CJOJQJU^JphsWQ##Z$\$$$$C=====$If$$Iflֈ p*'Eu,06sWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQ4 la$$$$$$$$$$$$$$$$%%%%%%%%%%%%%>&ٵٛٵٛqٵٛ\ٵ(j^#B*CJOJQJU^JphsWQ(j"B*CJOJQJU^JphsWQ(jr"B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQB*CJOJQJ^JphsWQB*CJ OJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu"jB*CJOJQJU^JphsWQ(j!B*CJOJQJU^JphsWQ$$$$$$$ %%%%$If %% & &&' '"'''VPPPPPPPP$If$$Iflr p*l u,06sWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQ4 la >&@&\&^&`&v&x&&&&&&&&&&&' ' '^'`'t'v'x''{nY{B-jB*CJOJQJU^JmHnHphsWQu(j%B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ"jB*CJOJQJU^JphsWQ(j6%B*CJ OJQJU^JphsWQ(j$B*CJ OJQJU^JphsWQ(jJ$B*CJ OJQJU^JphsWQ(j#B*CJ OJQJU^JphsWQB*CJ OJQJ^JphsWQ"jB*CJ OJQJU^JphsWQ''((( (4(6(8(B(D(H(J(Z(\(p(r(t(~((((((((((((µ‰|µg‰|µR‰(j'B*CJOJQJU^JphsWQ(j&B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ-jB*CJOJQJU^JmHnHphsWQu(j"&B*CJOJQJU^JphsWQB*CJOJQJ^JphsWQ"jB*CJOJQJU^JphsWQB*CJ OJQJ^JphsWQB*CJ OJQJ^JphsWQ"jB*CJOJQJU^JphsWQ'''((F(H(J(((((((v$$IflF y*4 #06 sWQsWQsWQ sWQ sWQsWQsWQ sWQ4 la$If (()H)z)|)~))))UH$$Ifl4\ y*xZ`#06sWQsWQsWQsWQsWQsWQsWQsWQsWQsWQsWQ4 la$If $dh$Ifa$ (()))**3*4****u+v+++,,..;.<.//d0e000000ĸsg^^V5B*\phrpB*CJRH`phsWQ5B*CJRH^\phsWQ5B*CJRHa\phsWQB*CJRH]phsWQ5B*CJRH\\aJphsWQB*CJRHaphsWQB*CJRHcphsWQB*CJRHaphsWQ B*CJphsWQ5>*B*RH[\phsWQB*CJ OJQJRHc^JphcB*CJOJQJRHc^JphcCJ B*CJ OJQJ^JphsWQB*CJOJQJ^JphsWQ))))))**2*3***++~uu $$Ifa$$a$s$$Ifl4D0y* #06sWQsWQsWQsWQsWQ4 la$If +--...00000 $7$8$H$IfZ$$Ifl{*+    0sWQsWQsWQsWQsWQsWQ6sWQsWQsWQsWQ4 la d $7$8$H$If$If 0000_111111d$If d $7$8$H$If $$Ifa$X$$Ifl*+  0sWQsWQsWQsWQsWQsWQ6sWQsWQ4 la 00_111111112 2 2222,2.22242>2B2D2X2Z2\2f2h2j2l2222222222222Ϧ{ϗn{Ϝjp(B*UphsWQjB*UmHnHphsWQuj'B*UphsWQ B*phsWQjB*UphsWQ B*CJphsWQjUmHnHuj'U jUCJ B*CJ phsWQ B*CJphsWQCJ 5B*CJ\phB*CJRH]phsWQB*CJRH\phsWQ5B*CJ\phsWQ)111112.2022242>2@2B2j2T$IfZ$$Ifl{*+   0sWQsWQsWQsWQsWQsWQ6sWQsWQsWQsWQ4 la j2l2222 3*3,3.3V3}wwwwwwww$If$$Ifl4 Fu*D  '  0sWQsWQsWQsWQsWQsWQ6  sWQ sWQsWQsWQ sWQ4 la 222222222233.303D3F3H3R3T3V3X3t3x3z33333333333333444444&4(4*4,4.404D4δӱӮΡ΍Ӯ΀Κj4+B*UphsWQj*B*UphsWQ B*CJphsWQjH*B*UphsWQCJCJ j)B*UphsWQj\)B*UphsWQ B*phsWQ B*CJphsWQjB*UmHnHphsWQujB*UphsWQj(B*UphsWQ1V3X3r3t3v3x333344444444X$Ifn$$Ifl4)0*;  0sWQsWQsWQsWQsWQsWQ6sWQsWQsWQsWQ4 laD4F4H4R4T4V4X4Z4\4p4r4t4~444444444ӾCJ B*CJphsWQCJ j ,B*UphsWQ B*phsWQ B*CJphsWQjB*UmHnHphsWQujB*UphsWQj+B*UphsWQ44444l$$Ifl40*;    0sWQsWQsWQsWQsWQsWQ6sWQsWQsWQsWQ4 la$If/ =!"#@$%vDText78tDText2tDText3tDText4tDeCheck1tDeCheck2tDeCheck3tDeCheck4tDeCheck5tDeCheck6tDeCheck7tDText7tDeCheck8tDText8tDeCheck9vDeCheck10tDText9vDeCheck11tDText6vDeCheck12vDeCheck13vDText10vDText11vDText12vDText13vDText14vDText18vDText19vDText20vDeCheck14vDeCheck15vDText15vDText16vDText17vDText22vDText23vDText24vDText25vDText21vDText26vDText27vDText28vDText29vDeCheck16vDeCheck17vDText58vDText59vDText60vDText61vDText62vDText63vDText64vDText65vDText74vDText75vDText76vDText77vDText30vDText31vDText32vDText33vDText34vDText53vDText52vDText54vDText36vDText35vDText37vDText38vDText39vDText40vDText41vDText42vDText43vDText44vDText45vDText46vDText47vDeCheck18vDeCheck19vDeCheck20vDeCheck21vDText48vDText49vDText50vDText51vDText66vDText79vDText55vDText56vDText57vDText68vDText69vDText70vDText71vDText72vDText73 i<@< NormalCJOJQJ_HmH sH tH <A@< Default Paragraph Fontv 6Q`abctw0123ABVWh !"#$%OP67OPQRSTst Tg} .[\p}  2FG[q >]^su   - . / C E Y n o ) * > I J K L k    z  4 A B C D K L M N T U V W \ ] ^  -ABV)-.Bwx(/0DIJ^dey}~-.BGH\bcw{|#$%ABC^_`z2_ 56CDEABPQRrstux0000000000000000000000000000000000000000000000000@00000000000000000000000000000000000000000000@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@00@0@0@0@0@0@0@0@0@0@0@0@0@0@0@00000000000000000000000@000000000000@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0000000000@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@000000@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@00000000@0000000000000000000000000000000000000000000000000N% n z R zTd!v"~#$>&'(02D44 $&(*+.02569<>CEGIKMPQTX[]"  \Lx$HP\ B!"#$%'()+01j2V344!"#%'),-/13478:;=?@ABDFHJLNORSUVWYZ\^4(.BNTP`7GTd  ,2?O .>FV\hn GSY '7DTv % + / ; A E Q W o {  * 6 < |     , 2 -9?BNT !'.:@x &0<BJV\eqw~.:@HTZcou|/;KWgu!-9?JV\ !-3FRX[gmq} #)-9?vFFtFtFtG$G$G$G$G$G$G$FtG$FtG$G$FtG$FtG$G$FtFFFFFFFG$G$FFFFFFFFFFFFG$G$FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFG$G$G$G$FFFFFFFFFFFFFFFDsWQ@0(  B S  ?vaText78Text2Text3Text4Check1Check2Check3Check4Check5Check6Check7Text7Check8Text8Check9Check10Text9Check11Text6Check12Check13Text10Text11Text12Text13Text14Text18Text19Text20Check14Check15Text15Text16Text17Text22Text23Text24Text25Text21Text26Text27Text28Text29Check16Check17Text58Text59Text60Text61Text62Text63Text64Text65Text74Text75Text76Text77Text30Text31Text32Text33Text34Text53Text52Text54Text36Text35Text37Text38Text39Text40Text41Text42Text43Text44Text45Text46Text47Check18Check19Check20Check21Text48Text49Text50Text51Text66Text79Text55Text56Text57Text68Text69Text70Text71Text72Text73CQ8U !@ /G] H (Ew 0 F p + } ! .C/y1Kf/Id} <Xv.K"G\r.x  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`/UaHe3P?WoZ8U, B X =  3 @U (A'C]xA[v0Lh"@] 4Yn*@x/BU 3 \o GZ v , / B E X o * =  3 -@BU (.Ax'0CJ]ex~.AH[cv|"-@J] !4FY[nq*-@x/BUhtuw 3 \o  26;FGZ v , / B E X o * = k q { |  C M N z  3   S `  @BU (),-.Ax'(./0CDHIJ]^cdexy|}~.ABFGH[\abcvwz{|"-@J](<_i !4FY[nq*-@x3333333333333333333333333/BU_`FGcd 3NO =>UV\o GZ 67STv , / B E X o * =  3 -@BU (.Ax'0CJ]ex~.AH[cv|./JKfg"-@J] !4FY[nq*-@uxcknight=C:\Documents and Settings\cknight\Desktop\Working Docs\E1.doccknight=C:\Documents and Settings\cknight\Desktop\Working Docs\E1.doccknight=C:\Documents and Settings\cknight\Desktop\Working Docs\E1.doccknight0D:\my documents\word\AutoRecovery save of E1.asdcknight=C:\Documents and Settings\cknight\Desktop\Working Docs\E1.doccknight=C:\Documents and Settings\cknight\Desktop\Working Docs\E1.doccknight=C:\Documents and Settings\cknight\Desktop\Working Docs\E1.docaerwin"G:\IT\HTMLDOC\new site\word\E1.doc Ewing CollierTC:\Documents and Settings\colliere\My Documents\Letters\Claims\Accident Forms\e1.doc Ewing CollierwC:\Documents and Settings\colliere\My Documents\Letters\Claims\Accident Forms\Employer Report of Injury (E1) DA1973.doc`0123VW "#$OPQRSTp[^ - C Y > K L   4 B C D L M N U V W ] ^ V)B(D^yB\w#A^ 56ABRtux@ H!  v@  "$&(T@24UnknownGz Times New Roman5Symbol3& z ArialY CG TimesTimes New Roman"hff3uFCK 3#20d2QOFFICE OF RISK MANAGEMENTcknight Ewing CollierOh+'0 , H T ` lxOFFICE OF RISK MANAGEMENT0FFIcknightknikniNormalEwing Collier M2inMicrosoft Word 9.0G@G@,~K@@CK՜.+,0 hp  State of Louisiana3  OFFICE OF RISK MANAGEMENT Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_abcdefghijklmnopqrstuvxyz{|}~Root Entry FWData `,1TablewPWordDocumentSummaryInformation(DocumentSummaryInformation8CompObjjObjectPoolWW  FMicrosoft Word Document MSWordDocWord.Document.89q