Wc-1, Employers First Report Of Injury Or Occupational Disease printable pdf download

WC-1 EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE

NOTE: FAILURE TO SUBMIT THIS REPORT TO INSURER IMMEDIATELY MAY RESULT IN PENALTY. MUST BE TYPED OR PRINTED IN BLACK INK.

Board Claim No.

Employee Last Name

Employee First Name

M.I.

Date of Injury

SSN or Board Tracking #

A. IDENTIFYING INFORMATION

Birthdate

Male

Phone Number

Employee E-mail

EMPLOYEE

Female

Address

City

State

Zip Code

Name

NAICS Code

Nature of Business (Trade, Transport, Mfg., etc.)

EMPLOYER

Address

Phone Number

Employer FEIN

City

State

Zip Code

Employer E-mail

Name

Insurer/Self-Insurer FEIN

Insurer/ Self-Insurer File #

INSURER /

SELF-INSURER

Name

Claims Office FEIN #

Claims Office Phone

Claims Office E-mail

CLAIMS OFFICE

SBWC ID# (five digit no.)

Address

City

State

Zip Code

Date Hired by Employer

Job Classified Code No.

Wage rate at time of

Number of Days Worked Per Week

per Hour

Injury or Disease:

EMPLOYMENT/WAGE

per Day

per Week

Insurer Type Code

List Normally Scheduled Days Off

per Month

– Insurer

S-Self-insurer

Group Fund

Date Employer had knowledge of

Enter First Date Employee Failed to Work

County of Injury

Time of Injury

Injury

a Full Day

INJURY/ILLNESS

& MEDICAL

Did Employee Receive Full

Did Injury/Illness Occur

Type of Injury/Illness

Body Part Affected

on Employer’s premises?

Pay on Date of Injury?

Yes

How Injury or Illness / Abnormal Health Condition Occurred

Treating Physician (Name and Address)

Initial Treatment Given:

Hospital / Treating Facility (Name and Address)

If Returned to Work, Give Date:

None

Minor: By Employer

Returned at what wage

per Week

Minor: Clinical/Hospital

Emergency Room

If Fatal, Enter Complete

Date of Death

Hospitalized > 24hrs

Report Prepared By (Print or Type)

Telephone Number

Date of Report

B. INCOME BENEFITS

Form WC-6 must be filed if weekly benefit is less than maximum

Previously Medical Only

Date of disability:

Yes

Average Weekly Wage: $

Weekly benefit: $

Date of first Payment:

Compensation paid: $

or Date salary paid:

Penalty paid: $

BENEFITS ARE PAYABLE FROM

FOR:

Temporary total disability

Temporary partial disability

Permanent partial disability of

% to

for

weeks.

UNTIL

WHEN THE EMPLOYEE ACTUALLY RETURNED TO WORK WITHOUT RESTRICTIONS. ALL OTHER SUSPENSIONS REQUIRE

THE FILING OF FORM WC-2 WITH THE STATE BOARD OF WORKERS’ COMPENSATION AND THE EMPLOYEE.

C. NOTICE TO CONTROVERT PAYMENT OF COMPENSATION

Benefits will not be paid because:

D. MEDICAL ONLY

No disability paid or controverted

INJURY

Insurer / Self-Insurer: Type or Print Name of Person Filing Form

Signature

Date

Phone and Ext.

E-mail

IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT

WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19).

EMPLOYER’S FIRST REPORT OF INJURY

WC-1

REVISION . 07/2011

OR OCCUPATIONAL DISEASE

1 OF 2

Wc-1, Employers First Report Of Injury Or Occupational Disease

Related Articles

Related forms

Related Categories