Georgia Form Wc 102B – Fill Out and Use This PDF

Georgia Form WC 102B is an important document that details the information pertinent to a worker's claim for Workers' Compensation. It provides an accurate record of frequently requested and required data required when filing a denied or contested workers' compensation case. The form itself consists of mandatory legal information which is related to employee identification, employer and insurance carrier details, along with facts related to the claimed occupational illness or injury undergoing adjudication by the Workers' Compensation Board. This form offers a comprehensive account of claimant information in such a way as to protect both employers, insurance providers and employees throughout any caseprocessing that may arise from a documented Workers' Comp incident.

Georgia Form Wc 102B PDF Details

Form WC 102B is a workers' compensation form that employers in the state of Georgia must use to report injuries or illnesses suffered by their employees. This form must be completed within seven days of the injury or illness, and it provides important information about the incident that can help facilitate the workers' compensation claim process. Employers should be familiar with the contents of this form and how to properly complete it so that they can provide accurate and timely information to their employees and to the Georgia Workers' Compensation Board.

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

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WC-102b NOTICE OF REPRESENTATION OF ANY PARTY OTHER THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY

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 E-mail

Address

City

State

Zip Code

ATTORNEY FOR EMPLOYEE / CLAIMANT

Name

EMPLOYER

Name

Address				Address

City		State	Zip Code	City		State	Zip Code

GA Bar number				Employer E-mail

Attorney E-mail				INSURER /	Name
				INSURER /
				SELF-INSURER

PARTY AT	Name			CLAIMS OFFICE	Name
INTEREST				CLAIMS OFFICE
INTEREST

Address				Address			SBWC ID # (five digit no.)

City		State	Zip Code	City		State	Zip Code

Party E-mail

Claims E-mail

B. NOTICE

This serves notice that Attorney:
of the firm:
at mailing address:
Telephone Number
	City	State	Zip Code
Fax Number	E-mail Address		GA Bar Number

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 30303-1299

Signature	E-mail Address	Date

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-102b	REVISION . 07/2011 102b	NOTICE OF REPRESENTATION OF ANY PARTY OTHER
		THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY

Georgia Form Wc 102B – Fill Out and Use This PDF

Georgia Form Wc 102B PDF Details

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