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 |
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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
Name
EMPLOYER
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INSURER / |
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PARTY AT |
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CLAIMS OFFICE |
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INTEREST |
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SBWC ID # (five digit no.) |
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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
Signature |
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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 |