Wc-14, Notice Of Claim

WC-14 NOTICE OF CLAIM

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

Check only one:

NOTICE OF CLAIM ONLY

REQUEST HEARING / NOTICE OF CLAIM

REQUEST FOR MEDIATION / NOTICE OF CLAIM

Complete a new Form WC-14 to add an additional employer, insurer or to add date of injury.

If you need additional space, do not alter this form, but instead attach additional sheets. Must be typed or printed in black ink.

Board Claim No.

Employee Last Name

Employee First Name

M.I.

SSN or Board Tracking #

Date of Injury

A. CLAIM INFORMATION

Birthdate

County of Injury

Address

EMPLOYEE

Employee E-mail

City

State

Zip Code

Name

Name

SBWC# (five digit #)

INSURER/

EMPLOYER

SELF- INSURER

Address

Name

CLAIMS OFFICE

Claims Address

City

State

Zip Code

City

State

Zip Code

Employer E-mail

Claims E-mail

Name

Name

ATTORNEY FOR

ATTORNEY FOR

EMPLOYEE/CLAIMANT

EMPLOYER/INSURER

Address

GA Bar Number

Address

GA Bar Number

City

State

Zip Code

City

State

Zip Code

Attorney E-mail

Attorney E-mail

3. If Fatal – Enter complete date of death

1. Part of Body Injured

2. First Date Disabled

Claimants for death benefits (list names & addresses) attach additional sheets

B. HEARING / MEDIATION ISSUES

Medical Benefits

TTD(Dates)

List Benefits

Income Benefits

TPD(Dates)

Effective Date



Suspension / Termination Request

 

PPD(Dates)

Late-Payment Penalties / Assessed Attorney Fees

Reason

§

§

§

Other

34-9-221e

34-9-108b (1)

34-9-108b(2)

Specify

Catastrophic Designation

Specify

Appeal of Rehabilitation Decision

Specify

 Other

Additional Board Claim Numbers which will be involved (if any):

(Complete a separate form WC14 for each date of accident)

C. AFFIRMATION OF FILING PARTY

I, [the person whose name appears above], attest and affirm that all information contained herein is true and correct to the best of my knowledge. I understand that

knowingly giving false information to obtain or deny workers’ compensation benefits subjects me to civil and criminal penalties.

D. ENTRY OF APPEARANCE

I hereby certify to the existence of a valid fee contract in compliance with Board Rule 108 or a Form WC-102B in compliance with Board Rule 102.

(fee contract or WC-102B has been previously filed or is attached)

E. CERTIFICATE OF SERVICE

I hereby certify that I have today sent a copy of this form to all of the parties named above, and have sent this form to the State Board of Workers' Compensation, 270

Peachtree St., NW, Atlanta, Georgia 30303-1299.

Print Name

Signature

Date

Phone Number

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).

14

WC-14

REVISION . 07/2011

NOTICE OF CLAIM

For injuries occurring on or after July 1, 2007, any claim filed with the Board for which neither medical nor income benefits have been paid shall stand dismissed with prejudice by operation of

law if no hearing has been held within five years of the alleged date of injury. (O.C.G.A. §34-9-100)