Georgia Wc 14 Form PDF Details

Understanding the intricacies of workers' compensation in Georgia is crucial for employees who find themselves injured on the job. Central to this process is the Form WC-14, also known as the "Notice of Claim." This form serves multiple purposes; it's used not only to notify the Georgia State Board of Workers' Compensation about an injury but also to request a hearing or mediation if necessary. It's a vital step in the claims process, ensuring the injured party's details, including name, date of injury, and a description of the accident, are formally documented. Moreover, it distinguishes between simply notifying about a claim and actively seeking a hearing or mediation, providing spaces to detail the nature of the injury, any dependents for death benefits, and issues for consideration like medical benefits and income benefits. Completeness and accuracy are paramount, as additional sheets can be attached if more space is needed without altering the form itself. The form emphasizes the legal responsibilities of the filing party, including the affirmation of truthfulness under penalty of civil and criminal consequences for falsehoods and the necessity of a certificate of service, confirming the form has been distributed to relevant parties. This article introduces readers to the foundational aspects of the WC-14 form, exploring its purpose, requirements, and significance in the broader workers' compensation claim process in Georgia.

QuestionAnswer
Form NameGeorgia Wc 14 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswc 14 form, georgia form sbwc, wc 4 georgia, wc 14

Form Preview Example

WC-14 NOTICE OF CLAIM

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

Check only one: NOTICE OF CLAIM ONLY REQUEST HEARING / NOTICE OF CLAIM REQUEST FOR MEDIATION / NOTICE OF CLAIM

Complete a new Form WC-14 to add an additional employer, insurer or to add date of injury.

If you need additional space, do not alter this form, but instead attach additional sheets. Must be typed or printed in black ink.

Board Claim No.

Employee Last Name

Employee First Name

M.I.

Date of Injury

A. CLAIM INFORMATION

EMPLOYEE

Birthdate

County of Injury

Mailing Address

Employee E-mail

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

INSURER/

 

Name

 

 

 

 

 

SBWC# (five digit #)

EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SELF- INSURER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

Zip Code

City

 

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer E-mail

 

 

 

 

 

 

 

 

 

Insurer E-mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTORNEY FOR

 

Name

 

 

 

ATTORNEY FOR

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEE/CLAIMANT

 

 

 

 

 

 

 

 

 

EMPLOYER/INSURER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

GA Bar Number

Mailing Address

 

 

 

 

 

 

 

 

GA Bar Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

Zip Code

City

 

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attorney E-mail

 

 

 

 

 

 

 

 

 

Attorney E-mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Part of Body Injured

 

 

 

 

 

 

 

 

2. First Date Disabled

 

 

3. If Fatal – Enter complete date of death

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claimants for death benefits (list names & addresses) attach additional sheets

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Description of Accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. HEARING / MEDIATION ISSUES

 

 

 

 

 

 

 

TTD(Dates)

 

 

 

 

 

Medical Benefits

List Benefits:

 

 

 

 

 

Income Benefits

 

 

 

 

 

 

 

 

 

 

 

TPD(Dates)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PPD(Dates)

 

 

 

 

Suspension / Termination Request

 

Effective Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason:

 

 

 

 

 

 

 

 

 

Dependency Benefits

 

Burial Expenses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Penalties / Assessed Attorney Fees

 

§34-9-221e

§34-9-108b (1)

§34-9-108b(2)

Other

 

 

 

 

 

 

 

 

 

 

 

 

Request for Catastrophic Designation

 

Specify:

 

Appeal of Rehabilitation Decision

Specify:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

Specify:

 

 

 

 

Additional Board Claim Numbers which will be involved (if any):

 

 

 

 

 

 

 

 

 

Hearing Issues

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Complete a separate form WC14 for each date of accident)

 

 

 

 

 

 

 

C. AFFIRMATION OF FILING PARTY

I, [the person whose name appears above], attest and affirm that all information contained herein is true and correct to the best of my knowledge. I understand that knowingly giving false information to obtain or deny workers’ compensation benefits subjects me to civil and criminal penalties.

D. ENTRY OF APPEARANCE

I hereby certify to the existence of a valid fee contract in compliance with Board Rule 108 or a Form WC-102B in compliance with Board Rule 102. (fee contract or WC-102B has been previously filed 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 and have sent this form to the State Board of Workers' Compensation, 270 Peachtree St., NW, Atlanta, Georgia 30303-1299.

Print Name

Signature

Date

Phone Number

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-14

REVISION 12/2018

14

NOTICE OF CLAIM

For injuries occurring on or after July 1, 2007, any claim filed with the Board for which neither medical nor income benefits have been paid shall stand dismissed with prejudice by operation of law if no hearing has been held within five years of the alleged date of injury. (O.C.G.A. §34-9-100)

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1. First, when filling in the georgia form sbwc, beging with the area that includes the following blank fields:

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2. Just after filling in the last part, go to the next stage and fill out all required particulars in these blanks - First Date Disabled, If Fatal Enter complete date of, B HEARING MEDIATION ISSUES, Medical Benefits, List Benefits, Suspension Termination Request, Effective Date, City Attorney Email Part of Body, Description of Accident, Income Benefits, TTDDates TPDDates PPDDates, Dependency Benefits Penalties, Request for Catastrophic, Other Hearing Issues, and Specify.

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