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You are here: Home / Adjusting Tools / Employment Agreement

Employment Agreement

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

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