Georgia Form Wc 100 PDF Details

Georgia Form WC 100 is an important document that employees in the state of Georgia must complete to file for workers' compensation benefits. The form is used to provide information about the injury or illness and the employee's claim for benefits. Workers' compensation is a system of insurance that provides benefits to employees who are injured or become ill as a result of their job. If you have been injured or become ill as a result of your job, it is important to understand how workers' compensation can help you. The Georgia Department of Labor has more information on workers' compensation and how to file a claim.

QuestionAnswer
Form NameGeorgia Form Wc 100
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names102B, WC-100, NW, E-mail

Form Preview Example

WC-100 SETTLEMENT MEDIATION REQUEST

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

REQUEST FOR SETTLEMENT MEDIATION

Board Claim No.

Employee Last Name

Employee First Name

M.I.

SSN or Board Tracking #

Date of Injury

A. IDENTIFYING INFORMATION

 

 

Name

 

 

 

 

 

 

Phone Number

 

County of Injury

 

EMPLOYER

 

 

 

 

 

EMPLOYEE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

Phone Number

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code

Employee E-mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer E-mail

 

 

 

 

INSURER /

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SELF-INSURER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PARTY AT INTEREST

Name

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

CLAIMS OFFICE

 

 

 

 

 

 

OR SITF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

Phone Number

Address

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code

Claims E-mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Party E-mail

ATTORNEY FOR

Name

 

EMPLOYEE/CLAIMANT

 

 

 

ATTORNEY FOR

Name

 

EMPLOYER / INSURER

 

 

 

Address

 

 

 

Phone Number

Address

 

Phone Number

City

 

State

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GA Bar Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

Attorney E-mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GA Bar Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. SETTLEMENT REQUEST INFORMATION

 

Attorney E-mail

 

 

 

 

MSA Involved?

 

Catastrophic Injury Designation?

 

SITF Accepted Claim?

 

 

 

 

 

 

Yes

No

Yes

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. CERTIFICATION

By the filing of this Request for Settlement Mediation, all parties certify that they agree to participate in mediation for the purpose of settlement of the above referenced claim(s). The parties hereby further certify that the employer/insurer or self-insurer has obtained, or will obtain by the date of the first setting of this matter, settlement authority based upon a good faith evaluation of this claim, and that all parties are otherwise prepared to go forward. If this claim involves a request for reimbursement from the Subsequent Injury Trust Fund, the parties hereby certify that the Fund has been made aware of the settlement conference or agrees to a settlement conference and has been provided with all necessary documentation.

D. ENTRY OF APPEARANCE

I hereby certify to the existence of a valid fee contract in compliance with Board Rule 108 or Form WC 102B filed in compliance of Board Rule 102. (A fee contract or Form WC 102B has been filed previously 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.

Signature of Employee Representative

Date

Signature of Employer/Insurer Representative

Date

Print Name and Telephone Number Here

Print Name and Telephone Number Here

E-mail

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 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-100

REVISION . 07/2011

100

SETTLEMENT MEDIATION REQUEST

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