Wc-102, Request For Documents To Parties

WC-102 REQUEST FOR DOCUMENTS TO PARTIES

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

REQUEST FOR DOCUMENTS TO PARTIES

Instructions:

NEITHER THE RESPONSE NOR REQUEST SHOULD BE FILED WITH THE BOARD. Prior to a request for hearing being filed in a claim,

the parties shall be entitled to receive from each other the documents specified in this form. These documents shall be provided without cost as requested

within 30 days of the date of the certificate of service. FAILURE OF THE PARTIES TO PROMPTLY EXCHANGE THESE DOCUMENTS MAY RESULT IN

THE ASSESSMENT OF PENALTIES AND ATTORNEY’S FEES [SEE BOARD RULE 102(F)(1)].

Board Claim No.

Employee Last Name

Employee First Name

M.I.

Date of Injury

SSN or Board Tracking #

A. IDENTIFYING INFORMATION

County of Injury

Address

City

State

Zip Code

EMPLOYEE

Name

Name

INSURER /

EMPLOYER

SELF-INSURER

Address

Name

CLAIMS OFFICE

City

State

Zip Code

Address

City

State

Zip Code

Name

Name

ATTORNEY FOR

ATTORNEY FOR

EMPLOYEE

EMPLOYER

Address

Address

City

State

Zip Code

City

State

Zip Code

B. PRODUCTION OF DOCUMENTS

1. The employee hereby requests production of the following documents in the possession of the employer / insurer:

Form WC-1

Form WC-104

Form WC-2

Form WC-200a

Form WC-2a

Form WC-200b

Form WC-3

Form WC-205

Form WC-4

Form WC-240 with supporting documents

Form WC-6

Form WC-243

Form WC-20a

Reports prepared pursuant to Rule 200.1.(f)

Form WC -R1, 2 and all rehabilitation supplier reports

Medical records pursuant to Board Rule 200 (f) (2)

Form WC- P1, 2 or 3 utilized by the employer on the date of accident

Actual wage records of employee:

/

/

/

/

Employee, from

to

/

/

/

/

Similarly situated employee, from

to

Copy of job description / analysis submitted to authorized treating physician

2. The employer / insurer hereby requests production of the following document in the possession of the employee / claimant:

(

)

Wage records applicable to calculation of TPD benefits

from

/

/

/

/

to

Medical records pursuant to Board Rule 200 (f) (1)

C. CERTIFICATION

I hereby certify that I have this day sent a copy of this document to the above-named parties.

Print Name

Signature

Date

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).

102

WC-102

REVISION . 07/2011

REQUEST FOR DOCUMENTS TO PARTIES