Wc-3, Notice To Controvert
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2WC-3 NOTICE TO CONTROVERT
GEORGIA STATE BOARD OF WORKERS' COMPENSATION
NOTICE TO CONTROVERT
Board Claim No.
Employee Last Name
Employee First Name
M.I.
SSN or Board Tracking #
Date of Injury
A. IDENTIFYING INFORMATION
Phone Number
Address
EMPLOYEE
Employee E-mail Address
City
State
Zip Code
Name
Phone Number
EMPLOYER
Address
City
State
Zip Code
Employer E-mail Address
Name
Insurer/Self-Insurer File #
INSURER/
SELF-INSURER
Name
Phone Number
CLAIMS
OFFICE
Address
SBWC ID# (five digit no.)
City
State
Zip Code
Claims Office E-mail Address
B.
1. This serves as notice, pursuant to O.C.G.A. 34-9-221, that the right to compensation in this claim is being controverted on the following
specific grounds:
2. This is notice, pursuant to O.C.G.A. 34-9-200 and Board Rule 205(b), that the compensability of the following medical treatment / test is
being controverted for the following specific reasons:
3. If only part of the claim is being controverted, state the specific part of the claim and the reason(s) it is being controverted:
C.
This is to certify that a copy of both sides of this notice has been sent to the employee / claimant(s), all counsel of record and any other person with
a financial interest, as listed below:
Type or Print Name
Signature
Date
Phone Number and Ext
E-mail Address
This form must be filed with the State Board of Workers' Compensation. A copy of both sides of this form must be given to the employee and any other
person with a financial interest in the claim including, but not limited to the employer, medical care provider(s) and attorney(s).
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).
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WC-3
REVISION . 07/2011
NOTICE TO CONTROVERT
1 OF 2
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