WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS
EMPLOYER (NAME & ADDRESS INCL ZIP)
Morehouse Parish School Board	CARRIER/ADMINISTRATOR CLAIM NUMBER	OSHA LOG NUMBER	REPORT PURPOSE CODE	
P O Box 872
Bastrop, LA 71221		JURISDICTION	JURISDICTION CLAIM NUMBER	
		INSURED REPORT NUMBER	
		EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT)	LOCATION #	
INDUSTRY CODE	EMPLOYER FEIN
72-6000917	4099 Naff Avenue, Bastrop,	LA 71220	PHONE #	

CARRIER/CLAIMS ADMINISTRATOR
CARRIER (NAME, ADDRESS, & PHONE #)
LUBA Worker's Comp P O Box 98082
Baton Rouge, LA 70898-9082
CARRIER FEIN	POLICY/SELF-INSURED NUMBER
028000018442121

POLICY PERIOD

8/1/25 TO 7/31/26
CHECK IF APPROPRIATE SELF INSURANCE

CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)
LUBA Worker's Compensation P O Box 98082
Baton Rouge, LA 70898-9082 (225) 389-5822
ADMINISTRATOR FEIN

AGENT NAME & CODE NUMBER
01352 Lauren Young, Risk Services of Louisiana, Inc.
EMPLOYEE/WAGE
NAME (LAST, FIRST, MIDDLE)	DATE OF BIRTH	SOCIAL SECURITY NUMBER	DATE HIRED	STATE OF HIRE

ADDRESS (INCL ZIP)	SEX

M MALE

MARITAL STATUS

U

UNMARRIED SINGLE/DIVORCED

OCCUPATION/JOB TITLE

EMPLOYMENT STATUS

F FEMALE
U UNKNOWN

M MARRIED
S SEPARATED

PHONE	# OF DEPENDENTS	K UNKNOWN	NCCI CLASS CODE

RATE	DAY	MONTH	DAYS WORKED/WEEK	FULL PAY FOR DAY OF INJURY?	YES	NO	
PER:

OCCURRENCE/TREATMENT	WEEK	OTHER:		DID SALARY CONTINUE?	YES	NO	

TIME EMPLOYEE BEGAN WORK

AM	DATE OF INJURY/ILLNESS PM

TIME OF OCCURRENCE

( ) CANNOT BE DETERMINED

AM	LAST WORK DATE PM

DATE EMPLOYER NOTIFIED

DATE DISABILITY BEGAN

CONTACT NAME/PHONE NUMBER	TYPE OF INJURY/ILLNESS	PART OF BODY AFFECTED

DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER’S PREMISES?

TYPE OF INJURY/ILLNESS CODE	PART OF BODY AFFECTED CODE

YES	NO
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL
CAUSE OF INJURY CODE

DATE RETURN(ED) TO WORK	IF FATAL, GIVE DATE OF DEATH	WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?

WERE THEY USED?

YES	NO
YES	NO

PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)	HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS)	INITIAL TREATMENT
0 NO MEDICAL TREATMENT
1 MINOR: BY EMPLOYER

2	MINOR CLINIC/HOSP
3	EMERGENCY CARE
4	
5

HOSPITALIZED > 24 HOURS
2	

OTHER
WITNESSES (NAME & PHONE #)

FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED

DATE ADMINISTRATOR NOTIFIED

LWC-WC IA-1

DATE PREPARED	PREPARER’S NAME & TITLE	PHONE NUMBER

IAIABC 2002

EMPLOYER’S INSTRUCTIONS

DO NOT ENTER DATA IN SHADED FIELDS

DATES:
Enter all dates in MM/DD/YY format.

INDUSTRY CODE:
This is the code which represents the nature of the employer’s business, which is contained in the Standard Industrial Classification Manual or the North American Industry Classification System, published by the Federal Office of Management and Budget.

CARRIER:
The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant.
CLAIMS ADMINISTRATOR:
Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering the claim.
AGENT NAME & CODE NUMBER:
Enter the name of your insurance agent and his/her code number if known. This information can be found on your insurance policy.

OCCUPATION/JOB TITLE:				
This is the primary occupation of the claimant at the time of the accident or exposure.	
EMPLOYMENT STATUS:				
Indicate the employee’s work status. The valid choices are:	
Full-Time	On Strike	Unknown	Volunteer	
Part-Time	Disabled	Apprenticeship Full-Time	Seasonal	
Not Employed	Retired	Apprenticeship Part-Time	Piece Worker	

DATE DISABILITY BEGAN:
The first day on which the claimant originally lost time from work due to the occupation injury or disease or as otherwise designated by statute.
CONTACT NAME/PHONE NUMBER:
Enter the name of the individual at the employer’s premises to be contacted for additional information.

TYPE OF INJURY/ILLNESS:
Briefly describe the nature of the injury or illness, (eg. Lacerations to the forearm).

PART OF BODY AFFECTED:
Indicate the part of body affected by the injury/illness, (eg. Right forearm, lower back).

DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (eg.
Maintenance Department or Client’s office at 452 Monroe St., Washington, DC 26210)

If the accident or illness exposure did not occur on the employer’s premises, enter address or location. Be specific.

LWC-WC IA-1	IAIABC 2002

EMPLOYER’S INSTRUCTIONS – cont’d

ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
(eg. Acetylene cutting torch, metal plate)

List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating when the injury or illness occurred. Be specific, for example: decorator’s scaffolding, electric sander, paintbrush, and paint.
Enter “NA” for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed do not have to be directly involved in the employee’s injury or illness.
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
(eg. Cutting metal plate for flooring)

Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation for painting.
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
Describe the work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter “NA” for not applicable if employee was not engaged in a work process (eg. walking along a hallway).

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL:
(Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against the hot metal.)
Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. For example: Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The worker’s right wrist was broken in the fall.
DATE RETURN(ED) TO WORK:
Enter the date following to most recent disability period on which the employee returned to work.

LWC-WC IA-1