Georgia Form Wc 3 PDF Details

In the intricate and legally nuanced sphere of workers' compensation in Georgia, the WC-3 form, formally known as the "Notice to Controvert," stands as a critical document employed by employers and insurers alike. Its primary function is to formally dispute a claimant's right to workers' compensation benefits under specified circumstances. This document is grounded in the regulations outlined by the Georgia State Board of Workers' Compensation, mandating a structured approach to disputing claims. The WC-3 form encompasses sections dedicated to providing exhaustive identification details of all parties involved, including the employee, employer, and insurer or self-insurer handling the claim. It further delves into the categorization of controvert types, essentially laying the framework for disputing either the entire claim, specific aspects such as medical treatments or tests, or isolating particular parts of a claim with detailed reasons for the contention. Such actions are governed by precise legal statutes and board rules, accentuating the importance of adhering to deadlines and procedural correctness to avoid potential penalizations, including attorney's fees and procedural costs. The intricate details encapsulated in the WC-3 form, from the initial notification to the certification of service, underscore its pivotal role in the workers' compensation claim process in Georgia, navigating the complex interplay between legal mandate, employer obligations, and the rights of the injured employee. This form not only serves as a notice but also as a procedural guide, ensuring that all parties are adequately informed and that any intentions to controvert a claim are thoroughly documented and communicated in compliance with Georgia's workers' compensation laws.

QuestionAnswer
Form NameGeorgia Form Wc 3
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesWC 003(1) georgia state board of workers compensation form wc 3

Form Preview Example

WC-3 NOTICE TO CONTROVERT

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

NOTICE TO CONTROVERT

Board Claim No.

Employee Last Name

Employee First Name

M.I.

Date of Injury

 

 

 

 

A. IDENTIFYING INFORMATION

 

 

 

 

 

EMPLOYEE

 

Mailing Address

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee E-mail Address

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER

 

Name

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

Employer E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURER/

 

Name

 

 

Insurer/Self-Insurer File #

 

 

 

 

 

 

 

 

 

SELF-INSURER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIMS

 

Name

 

 

Claims Office E-mail

 

 

 

 

 

 

 

 

 

 

 

OFFICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SBWC ID

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

B. CONTROVERT TYPES

1. This serves as notice, pursuant to O.C.G.A. §34-9-221, that the right to compensation in this claim is being controverted on the following

 

specific grounds:

 

 

 

2.

This is notice, pursuant to O.C.G.A. §34-9-200 and Board Rule 205(b), that the compensability of the following medical treatment / test is

 

 

being controverted for the following specific reasons:

 

 

 

3.

If only part of the claim is being controverted, state the specific part of the claim and the reason(s) it is being controverted:

 

 

 

 

 

C. CERTIFICATE OF SERVICE

 

 

This is to certify that a copy of both sides of this notice has been sent to the employee / claimant(s), all counsel of record and any other person with

 

a financial interest, as listed below:

 

 

 

 

 

 

 

 

 

 

 

 

 

Type or Print Name

 

Signature

 

Date

 

 

 

 

 

Phone Number

 

E-mail Address

 

 

 

 

This form must be filed with the State Board of Workers' Compensation. A copy of both sides of this form must be given to the employee and any other

person with a financial interest in the claim including, but not limited to the employer, medical care provider(s) and attorney(s).

 

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-3

REVISION 12/2018

3

NOTICE TO CONTROVERT

 

 

 

1 OF 2

 

 

WC-3

NOTICE TO CONTROVERT

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

INFORMATION FOR THE INSURER/SELF-INSURER:

Board Rule 61(b)(1): An insurer who receives a Form WC-1 from an employer shall clearly stamp the date of receipt on the form, review Section A, and complete any unanswered questions. The insurer shall complete either Section B or Section C or Section D and, by the 21st day following the employer's knowledge of disability, forward the original to the Board and a copy to the employee.

Board Rule 61(b)(4): previously been filed. 9-221 and Rule 221.

Form WC-3. Notice to Controvert Payment of Compensation. Complete Form WC-3 to controvert when a Form WC-1 has Furnish copies to employee and any other person with a financial interest in the claim. See subsections (d), (h), and (i) of Code §34-

O.C.G.A. §34-9-221(d): If the employer controverts the right of compensation, it shall file with the Board, on or before the twenty-first day after knowledge of the alleged injury or death, a notice in accordance with the form prescribed by the Board, stating that the right of compensation is controverted and stating the name of the claimant, the name of the employer, the date of the alleged injury or death, and the ground upon which the right to compensation is controverted.

Board Rule 221(d): To controvert in whole or in part the right to income benefits or other compensation use Form WC-1 or WC-3. Failure to file the Forms WC-1 or WC-3 before the 21st day after knowledge of the injury or death may subject the employer/insurer to assessment of attorney's fees. See O.C.G.A. §34-9-108(b)(2)(3).

O.C.G.A. §34-9-221(h): When compensation is being paid without an award, the right to compensation shall not be controverted except upon the grounds of change in condition or newly discovered evidence unless a notice to controvert is filed with the Board within 60 days of the due date of first payment of compensation.

Board Rule 221(h)(1): A Form WC-3 shall not be used to suspend benefits if the only issue is length of disability. In these cases, suspend benefits by filing a Form WC-2 or follow the procedure outlined in Rule 240. If liability is denied subsequent to commencement of payment, but within 60 days of due date of first payment of compensation, file Form WC-3 in addition.

O.C.G.A. §34-9-221(i): When compensation is being paid with or without an award and an employer or insurer elects to controvert on the grounds of a change in condition or newly discovered evidence, the employer shall, not later than 10 days prior to the due date of the first omitted payment of income benefits, file with the Board and the employee or beneficiary a notice to controvert the claim in a manner prescribed by the Board.

Board Rule 221(h)(2): If income benefits have been continued for more than 60 days after the due date of first payment of compensation, benefits may be suspended only on the grounds of a change in condition or newly discovered evidence. File Forms WC-2 or WC-2(a). When controverting a claim based on newly discovered evidence, file Form WC-3 also.

O.C.G.A. §34-9-108(b)(2): If any provision of Code Section §34-9-221, without reasonable grounds, is not complied with and a claimant engages the services of an attorney to enforce rights under that Code Section and the claimant prevails, the reasonable fee of the attorney, as determined by the Board, and the costs of the proceedings may be assessed against the employer.

INFORMATION FOR THE EMPLOYEE:

This claim is being controverted for the reason(s) indicated on the front of this form. If you disagree, you should request a hearing by sending Form WC-14 to the State Board of Workers’ Compensation at the address below. If you need a Form WC-14, please contact the State Board of Workers’ Compensation at the phone numbers listed below or visit the website.

STATE BOARD OF WORKERS' COMPENSATION

270 Peachtree Street, N.W. Atlanta, Georgia 30303-1299 In Atlanta: 404-656-3818

or: 1-800-533-0682

http://www.sbwc.georgia.gov

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-3

REVISION 12/2018

3

NOTICE TO CONTROVERT

 

 

2 OF 2

 

How to Edit Georgia Form Wc 3 Online for Free

It really is quite simple to fill in the Georgia Form Wc 3. Our editor was created to be easy-to-use and enable you to fill in any PDF easily. These are the steps to go through:

Step 1: Search for the button "Get Form Here" and select it.

Step 2: So you will be on your file edit page. You can include, update, highlight, check, cross, insert or remove areas or phrases.

For each part, fill in the information requested by the system.

stage 1 to filling in Georgia Form Wc 3

In the segment This serves as notice pursuant, specific grounds, B CONTROVERT TYPES, This is notice pursuant to OCGA, being controverted for the, If only part of the claim is, This is to certify that a copy of, C CERTIFICATE OF SERVICE, Type or Print Name, Phone Number, Signature, Email Address, Date, and This form must be filed with the write down the data that the program requests you to do.

part 2 to entering details in Georgia Form Wc 3

Step 3: When you select the Done button, the finished document is simply transferable to each of your devices. Or alternatively, you will be able to send it through mail.

Step 4: Try to get as many duplicates of your document as you can to avoid possible troubles.

Watch Georgia Form Wc 3 Video Instruction

Georgia Form Wc 3 isn’t the one you’re looking for?

Related Documents

  • Wc Rfi Form

    "... Texas workers com penstion and employers liability manual (wc rfst) reprint effective May 1994. Request for information The following ownership statements can be used to establish premiums under your workers compensation plan. Complete column ownership ..."

  • Ga Wc 10

    "... Ga Wc 10 ..."

  • State Of New Mexico Form Wc 1

    "... State Of New Mexico Form Wc 1 ..."

  • Wc 00 03 13

    "... Workers compensation and employer liability insurance policy Wc 0003 13 ed84 waiver of our rights to recover from others endorsement We have the right of recovering our payments against anyone who is responsible for injuries ..."

Please rate Georgia Form Wc 3

1 Votes

Related Resources

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .