Georgia Wc 14 Form – Fill Out and Use This PDF

Georgia WC 14 Form is a legally mandated form used in the state of Georgia due to the lack of various worker's compensation benefits that regular employees enjoy. This form provides supplemental security for workers who don't normally receive these benefits, ensuring they’re protected should an unexpected event or injury occur while on the job. It covers everything from medical costs to disability or death as a result of an occupational injury. It also outlines procedures to be followed in filing claims, appeal rights and even victims’ rights such as compensation for lost earnings or calculation methods used. With employers seeking ways to comply with the mandatory regulations, having knowledge of the Georgia WC 14 form has become increasingly important in protecting both employers and employees.

Georgia Wc 14 Form PDF Details

If you are a business owner in the state of Georgia, you will want to be aware of the new Georgia WC 14 form. This form is used to report workers' compensation insurance premiums and payments, so it is important that you understand how it works and what is required. In this blog post, we will give you an overview of the Georgia WC 14 form and explain how to complete it. We also provide a downloadable template for your convenience. Let's get started!

Question	Answer
Form Name	Georgia Wc 14 Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	wc 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

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

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:
	Request for Catastrophic Designation							Appeal of Rehabilitation Decision

	Other		Specify:					Additional Board Claim Numbers which will be involved (if any):
	Other
	Hearing Issues
	Hearing Issues						 (Complete a separate form WC14 for each date of accident)
							 (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

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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Pay attention while completing this form. Make sure every single blank is completed accurately.

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

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.

People often get some points incorrect while filling out Dependency Benefits Penalties in this area. Be sure you double-check everything you enter right here.

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Georgia Wc 14 Form – Fill Out and Use This PDF

Georgia Wc 14 Form PDF Details

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