Louisiana Notice of Compliance to Employees Mandatory

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An Equal Opportunity Employer Program. Auxiliary aids and services are a\
vailable upon request to individuals with disabilities. 1-800-259-5154 (TDD)	
Notice shall be given by 
delivering it or sending it 
by certifi ed mail or return 
receipt requested to:
Employer Representative
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Employer
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____________________________	R.S. 23:1302 states that this 
notice should be posted in a 
convenient and conspicuous 
place in the employer’s place of 
business.
Revised May 20 03	
Reporting Injury  	You should report to your employer any occupational disease or 
personal injury that is work-related, even if you deem it to be minor.	Occupational Disease or Death 	In case of an occupational disease, all claims are barred unless the 
employee  fi les a claim with his/her employer within one year of the 
date that:
1   the disease manifests itself.
2   the employee is disabled as a result of the disease.
3  the employee knows or has reasonable grounds to believe that the  disease is occupationally related.
In case of death arising from an occupational disease, all claims 
are barred unless the dependent(s) fi  le a claim with the deceased 
employee’s employer within one year of:
1   the date of death.
2   the date the claimant has reasonable grounds to believe that the  death resulted from occupational disease.	Filing Notice  	In case of injury or death caused by a work-related accident, an injured 
employee or any person claiming to be entitled to compensation either 
as a claimant or as a representative of a person claiming to be entitled 
to compensation, must give notice to the employer within 30 days of 
the injury. If notice is not given within 30 days, no payments will be 
made for such injury or death. In addition, any fraudulent action by the 
employer, employee, or any other person for the purpose of obtaining 
or defeating any bene fi t or payment of workers’ compensation shall 
subject such person to criminal as well as civil liabilities.
The above mentioned notice should be  fi led with the employer at the 
address shown to the right. A notice so given shall not be held invalid because of any inaccuracy in 
stating the time, place, nature or cause of injury, or otherwise, unless 
it is shown that the employer was in fact misled to his detriment 
thereby. Failure to give notice may not harm the employee if the 
employer knew of the accident or if the employer was not prejudiced 
by the delay or failure to give notice.	
Physicians 	In the event you are injured, you are entitled to select a physician 
of your choice for treatment. The employer may choose another 
physician and arrange an examination which you would be required 
to attend.	Formal Claim 	In order to preserve your right to bene
fi ts under the Louisiana 
Workers’ Compensation Law, you must  fi le a formal claim with the 
Of fi ce of Workers’ Compensation Administration within one year after 
the accident if payments have not been made or within one year after 
the last payment of weekly bene fi ts.	Information	If you desire any information regarding your rights and entitlement to 
bene fi ts as prescribed by law, you may call or write to the Of fi ce of 
Workers’ Compensation Administration, Post Of fi ce Box 94040, Baton 
Rouge, Louisiana 70804 - 9040 or telephone (225) 342-7555.	Name and Address of Insurance Company	________________________________________________________________________\
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