In Georgia, navigating the complexities of workers' compensation claims involves numerous steps and detailed processes, one of which includes proper notification when an attorney represents any party other than a claimant or employee. The WC-102b form, specifically designed by the Georgia State Board of Workers' Compensation, plays a critical role in this process. Its primary function is to notify the Board and all involved parties that an attorney is representing an entity other than an employee or claimant in a workers' compensation case. This could include employers, insurers, or self-insurers, among others. Essential parts of the form include identifying information about the employee, details of the attorney and the party they are representing, and a certification section that the attorney fills out to confirm the notice has been correctly distributed. The form also carries a caution against making false statements, highlighting the legal implications of such actions. Understanding the importance and correct use of the WC-102b form is essential for all stakeholders to ensure clear communication and adherence to Georgia's workers' compensation laws.
| Question | Answer |
|---|---|
| Form Name | Georgia Form Wc 102B |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | ga representation form, notice representation party attorney, georgia any party, georgia notice representation |
GEORGIA STATE BOARD OF WORKERS' COMPENSATION
NOTICE OF REPRESENTATION OF ANY PARTY
OTHER THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY
(This form is not to be filed by an attorney for claimant / employee)
Board Claim No.
Employee Last Name
Employee First Name
M.I.
SSN or Board Tracking #
Date of Injury
A. IDENTIFYING INFORMATION
County of Injury
EMPLOYEE
Employee
Address
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State
Zip Code
ATTORNEY FOR EMPLOYEE / CLAIMANT
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EMPLOYER
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CLAIMS OFFICE |
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Party
Claims
B. NOTICE
This serves notice that Attorney: |
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of the firm: |
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at mailing address: |
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Is counsel in this case for the following named party / parties:
C. CERTIFICATION
I certify that I have today sent a copy of this form to all parties named above and to the State Board of Workers’ Compensation, 270 Peachtree Street N.W., Atlanta, GA
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IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT
REVISION . 07/2011 102b |
NOTICE OF REPRESENTATION OF ANY PARTY OTHER |
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THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY |