Forms

Louisiana

These forms are included in your injured worker packet.

First Report of Injury
This form is used to report a work-related injury or illness to Summit. The copy in your injured worker packet includes the information given to Summit when your injury was reported to us. Keep that copy for your records.

Travel Reimbursement
Your mileage may be reimbursed for travel to and from a medical provider. To receive this benefit, you must complete this form and return it to Summit.

Employee Certificate of Compliance
In order to receive benefits, you must complete this form and return it to Summit within 14 days of the date you received your injured worker packet.

Physician's Choice
Complete this form and return to Summit as soon as possible, designating your choice of physician. Be sure it includes both your signature and the signature of an authorized representative of your employer. If you would like assistance in choosing your doctor, your Summit claims adjustor can help you find a physician qualified to treat your injury.