Form Wc R2 – Fill Out and Use This PDF

Form Wc R2 is an important document in the employment process. Critical information such as employee eligibility, compensation, and withholding are included to comply with tax rules and regulations. Filling out Form WcR2 accurately saves time throughout the hiring process and helps to validate your employees' records for a variety of governmental mandates. This form also serves to provide employers legal protection when complying with governmental requirements by representing employee withholdings that may be needed to meet certain instructions. The importance of Form WcR2 lies in its ability to help employers remain compliant while hiring new personnel. Additionally, it guards everyone involved in the hiring process by ensuring proper validation of employee records and cross-checking validations with established governmental standards..

Form Wc R2 PDF Details

Form Wc-R2 is a workers' compensation insurance form used in the state of California. This form is used to report an injury or illness that occurred while on the job. Workers' compensation insurance provides medical and financial benefits to employees who are injured or become ill as a result of their work. The WC-R2 form must be filed within five days of the date of the injury or illness. If you have been injured or become ill as a result of your work, be sure to file a WC-R2 form with the appropriate government agency.

Question	Answer
Form Name	Form Wc R2
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	wc r2 dbhdd wc 6 wage statement form

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WC-R2 REHABILITATION TRANSMITTAL FORM

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

REHABILITATION TRANSMITTAL FORM

Board Claim No.

Employee Last Name

Employee First Name

M.I.

Social Security Number

Date of Injury

	SECTION 1	IDENTIFYING INFORMATION
	Occupation		Catastrophic Injury?			County of Injury		Birthdate
EMPLOYEE			0	Yes
			0	No
Diagnosis & Functional Restrictions					Date last plans submitted / If expired, give reason

							New Plan Expectation Date

SECTION 2 REASON FOR REPORT

0As Directed by the Board

090-Day Report for Catastrophic Case

0Non-Catastrophic Medical Care Report

0Preparing for a Rehabilitation conference

(Attach Rehabilitation Progress Reports and Medical Reports)

0Other (Specify):

SECTION 3 ATTACHMENTS

(You must attach all appropriate documents not previously submitted)

0	Initial Rehabilitation Report	0	Labor Market Survey
0	Rehabilitation Progress Reports	0	Job Analysis
0	Medical / Therapy Reports	0	Release to Return to Work
0	Physical Capacity Evaluation Reports	0	Training Progress Reports
0	Psychological Evaluation Reports	0	Transferable Skills Analysis

0Vocational Evaluation Reports

0Other (Specify):

SECTION 4 SUMMARY

(Please provide a concise statement of activity, progress and recommendations)

IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov

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).

WC-R2	REVISION . 07/2007	R2	REHABILITATION TRANSMITTAL FORM
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WC-R2 REHABILITATION TRANSMITTAL FORM

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

SECTION 5 CERTIFICATE OF SERVICE

This section must be completed by the requesting party.

0 I certify that I have mailed copies to the following parties on

at the current addresses below.

Month

Day

Year

Signature

Registration No.

Rehabilitation Supplier Name

Telephone

Address

E-mail Address

City

State

Zip Code

Last Name

First Name

M.I.

Address

EMPLOYEE

E-mail Address

Telephone Number

City

State

Zip Code

Name

Address

EMPLOYER

E-mail Address

Telephone Number

City

State

Zip Code

INSURER /

Name

Address

SELF-INSURER

Name

CLAIMS OFFICE

E-mail Address

Telephone Number

City

State

Zip Code

EMPLOYEE’S

Name

Address

ATTORNEY

E-mail Address

Telephone Number

City

State

Zip Code

EMPLOYER’S

Name

Address

ATTORNEY

E-mail Address

Telephone Number

City

State

Zip Code

Name

Address

SITF

E-mail Address

Telephone Number

City

State

Zip Code

Is this case applicable for Kid’s Chance scholarships? 0 Yes 0 No

If yes, submit application to Kid’s Chance, Inc.

SECTION 6

APPROVAL / OBJECTIONS, TWENTY (20) DAY NOTICE

Absent written objections within 20 days of the date mailed, the rehabilitation request is approved effective the date of the certificate of service. No further correspondence will be issued by the Board. If there is an objection:

(1) The Objection must be in writing.

(2) It must be received by the Georgia State Board of Workers’ compensation within 20 days of the date of the Certificate of Service.

(3) A Certificate of Service must be completed stating that copies of the written objections were placed in the mail to all parties and the principal rehabilitation supplier the same date as the Certificate of Service.

IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov

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).

WC-R2	REVISION . 07/2007	R2	REHABILITATION TRANSMITTAL FORM
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Form Wc R2 – Fill Out and Use This PDF

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