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Fill a Valid Georgia Wc 102B Template

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The Georgia WC 102B form plays a critical role in the workers' compensation process, specifically when an attorney represents a party other than the claimant or employee. This form is essential for ensuring that all parties involved in a workers' compensation case are properly notified of legal representation. It captures vital information, including the names and contact details of the employee, employer, and attorney, along with the specifics of the case such as the Board Claim Number and date of injury. The form requires the attorney to certify that a copy has been sent to all relevant parties and the Georgia State Board of Workers' Compensation, which is crucial for maintaining transparency and accountability in the legal process. By providing clear identification of the parties involved, the WC 102B helps to streamline communication and fosters a more organized approach to handling workers' compensation claims. Furthermore, it underscores the importance of accurate documentation in legal proceedings, as any false statements made on this form can lead to significant penalties. Understanding the nuances of this form is essential for anyone navigating the complexities of workers' compensation in Georgia.

Georgia Wc 102B Example

WC-102b NOTICE OF REPRESENTATION OF ANY PARTY OTHER THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY

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 E-mail

Address

City

State

Zip Code

ATTORNEY FOR EMPLOYEE / CLAIMANT

Name

EMPLOYER

Name

 

Address

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

Zip Code

City

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

GA Bar number

 

 

 

 

Employer E-mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attorney E-mail

 

 

 

 

INSURER /

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SELF-INSURER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PARTY AT

Name

 

 

CLAIMS OFFICE

Name

 

 

INTEREST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

Address

 

 

 

SBWC ID # (five digit no.)

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

Zip Code

City

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

Party E-mail

Claims E-mail

B. NOTICE

This serves notice that Attorney:

 

 

 

of the firm:

 

 

 

at mailing address:

 

 

 

Telephone Number

 

 

 

 

City

State

Zip Code

Fax Number

E-mail Address

 

GA Bar Number

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 30303-1299

Signature

E-mail Address

Date

 

 

 

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-102b

REVISION . 07/2011 102b

NOTICE OF REPRESENTATION OF ANY PARTY OTHER

THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY
Download Georgia Wc 102B

Document Breakdown

Fact Name Fact Description
Form Purpose The WC-102B form serves as a notice of representation for any party other than a claimant or employee by an attorney.
Governing Law This form is governed by the Georgia Workers' Compensation Act, specifically O.C.G.A. § 34-9-18 and § 34-9-19.
Filing Requirement Attorneys representing claimants or employees do not file this form.
Information Required Essential information includes the employee's name, date of injury, and the attorney's contact details.
Certification Statement The attorney must certify that a copy of the form has been sent to all relevant parties and the State Board of Workers’ Compensation.
Submission Address The form must be sent to the State Board of Workers’ Compensation at 270 Peachtree Street N.W., Atlanta, GA 30303-1299.
Contact Information For questions, individuals can contact the State Board of Workers’ Compensation at 404-656-3818 or 1-800-533-0682.
Penalties for False Statements Submitting false information can lead to penalties up to $10,000 per violation.
Revision Date The WC-102B form was last revised in July 2011.
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