Submit a Claim - Louisiana Restaurant Association

Submit a Claim

Please complete as much of the following form to submit your LRA Workers' Comp claim. If you do not have all of the information, we still ask that you submit your form. Once you submit your form, a member of our LRA Workers' Comp Claims Department will be in touch to continue the process.

If you have any questions, please contact the LRA Workers' Comp Claims Department at claims@lra.org or (504) 454-2277.

Fields marked with an * are required.

Name of Person Reporting the Claim *

Phone *

Email *

Accident Date

Accident Time

Please indicate a.m. or p.m.

Date Reported to Employer

Employer Policy Number

Employer Name *

Employer Address

Employee Name *

Employee Address

Employee Social Security Number

Employee Gender

Employee Date of Birth

Employee Phone Number

Medical Only Claim: No Time Loss

Yes

Last Date Worked

Date Returned to Work

Supervisor Name

Supervisor Phone Number

Supervisor Email *

Hire Date

Employee Start Time on Day of Accident

Occupation

Type of Employee

Regular

Part-Time

Other

Contact Name for Wage Information

Phone Number

Method of:

Hourly

Salary

Other

Rate: $

Gross Salary: $

Pay Period:

Daily

Weekly

Bi-weekly

Other

Questionable Claim:

Yes

If yes, please explain

Second Injury Board Knowledge Questionnaire:

On File:

Post-Accident Drug Policy

Drug Screen Performed

Yes

Unknown

If no, please explain

Results:

Positive

Negative

Awaiting

Company able to accommodate light duty?

Yes

If yes, explain

Accidient Occurred on Premises:

If no, accident location & description

Witnesses: Please list names and phone numbers

Explain Accident: Please be specific and include body part(s).

Motor Vehicle Accident?

Name of Police Department Involved

First Aid Provided at the Scene

Name of Hospital

Hospitality Address

Name of Physican

Phone Number

Diagnosis

Treatment Description

Additional Information

Second Injury Board Knowledge Questionnaire

Please upload a copy of the Second Injury Board Knowledge Questionnaire:

20MB max

Please verify that you have checked the “I'm not a robot” checkbox.