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Fill a Valid Georgia Wc 100 Template

Name: Free Georgia Wc 100 Form ⋆ PDF Template
Brand: Forms Georgia
Rating: 4.842105 (19 reviews)

The Georgia WC 100 form is a crucial document used to request settlement mediation in workers' compensation cases. It serves as a formal request to the Georgia State Board of Workers' Compensation, allowing parties involved in a claim to engage in mediation for the purpose of reaching a settlement. Understanding this form is essential for employees, employers, and insurers alike, as it outlines the necessary information and certifications required to proceed with mediation.

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Contents

The Georgia WC-100 form serves as a crucial tool in the workers' compensation process, specifically for those seeking to resolve disputes through mediation. This form is utilized by employees, employers, and their respective legal representatives to formally request a settlement mediation conference. It collects essential identifying information such as the names, contact details, and claim numbers of the parties involved. Additionally, it prompts the parties to disclose critical details about the claim, including the date of injury and whether a Medicare Set-Aside (MSA) is involved. The WC-100 also includes sections for certifying participation in mediation, confirming the existence of a valid fee contract, and ensuring that all parties have received a copy of the form. By signing this document, all involved parties affirm their readiness to engage in mediation and their commitment to good faith negotiations. This structured approach not only facilitates communication but also helps ensure compliance with Georgia's workers' compensation regulations.

Georgia Wc 100 Example

WC-100 SETTLEMENT MEDIATION REQUEST

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

REQUEST FOR SETTLEMENT MEDIATION

Board Claim No.

Employee Last Name

Employee First Name

M.I.

SSN or Board Tracking #

Date of Injury

A. IDENTIFYING INFORMATION

Name

Phone Number

County of Injury

EMPLOYER

EMPLOYEE

Address

Phone Number

Address

City

State

Zip Code

City

State

Zip Code

Employee E-mail

Employer E-mail

INSURER /

Name

SELF-INSURER

PARTY AT INTEREST

Name

CLAIMS OFFICE

OR SITF

Address

Phone Number

Address

Phone Number

City

State

Zip Code

City

State

Zip Code

Claims E-mail

Party E-mail

ATTORNEY FOR	Name
ATTORNEY FOR
EMPLOYEE/CLAIMANT

ATTORNEY FOR	Name
ATTORNEY FOR
EMPLOYER / INSURER

Address

Phone Number

Address		Phone Number		City			State		Zip Code

				GA Bar Number

City	State		Zip Code	Attorney E-mail

GA Bar Number
					B. SETTLEMENT REQUEST INFORMATION
Attorney E-mail					MSA Involved?		Catastrophic Injury Designation?		SITF Accepted Claim?
					Yes	No	Yes	No	Yes	No

C. CERTIFICATION

By the filing of this Request for Settlement Mediation, all parties certify that they agree to participate in mediation for the purpose of settlement of the above referenced claim(s). The parties hereby further certify that the employer/insurer or self-insurer has obtained, or will obtain by the date of the first setting of this matter, settlement authority based upon a good faith evaluation of this claim, and that all parties are otherwise prepared to go forward. If this claim involves a request for reimbursement from the Subsequent Injury Trust Fund, the parties hereby certify that the Fund has been made aware of the settlement conference or agrees to a settlement conference and has been provided with all necessary documentation.

D. ENTRY OF APPEARANCE

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

Signature of Employee Representative

Date

Signature of Employer/Insurer Representative

Date

Print Name and Telephone Number Here

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-100

REVISION . 07/2011

100

SETTLEMENT MEDIATION REQUEST

Download Georgia Wc 100

Document Breakdown

Fact Name	Details
Form Purpose	The WC-100 form is used to request mediation for settlement in workers' compensation claims in Georgia.
Governing Law	This form is governed by the Georgia Workers' Compensation Act, specifically O.C.G.A. §34-9-18 and §34-9-19.
Parties Involved	The form must be completed by the employee, employer, and their respective representatives.
Submission Requirement	A copy of the form must be sent to all parties involved and to the State Board of Workers' Compensation.
Certification	All parties certify their agreement to participate in mediation and confirm the employer/insurer has settlement authority.
Contact Information	Questions can be directed to the State Board of Workers’ Compensation at 404-656-3818 or 1-800-533-0682.

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