As provided in Louisiana Revised Statute 23:1035.1(4) and in consideration for the offer of employment by ________________________________________________, I, ________________________________________________, agree to elect the workers’ compensation laws of Louisiana as my exclusive remedy should I sustain an injury or occupational disease while employed by ________________________________________________ regardless of the location or state in which that injury or occupational disease occurs. I further affirm that I am currently domiciled (have my habitual residence) in Louisiana.
Signed this ____________________ day of _______________________, 20____, in the Parish of ______________________________________________.
______________________________________________
EMPLOYEE
______________________________________________
AUTHORIZED EMPLOYER REPRESENTATIVE