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Fill a Valid Georgia Wc 14 Template

The Georgia WC-14 form is a crucial document used to notify the Georgia State Board of Workers' Compensation about a claim related to workplace injuries. This form allows employees to formally submit a claim or request a hearing or mediation regarding their workers' compensation benefits. Proper completion and timely submission of the WC-14 are essential for ensuring that claims are processed efficiently.

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Contents

The Georgia WC-14 form plays a crucial role in the workers' compensation process within the state. This form serves as a formal notice of claim, allowing employees to assert their rights when they have suffered injuries on the job. It can be used in various situations, including simply notifying the board of a claim, requesting a hearing, or seeking mediation. When completing the WC-14, individuals must provide essential information such as their name, date of injury, and details about the employer and insurer involved. The form also includes sections to specify the nature of the claim, including medical benefits and income benefits, along with any additional issues related to the case. Importantly, it requires an affirmation of the accuracy of the information provided, ensuring that all parties are held accountable for the details submitted. Furthermore, the WC-14 emphasizes the necessity of compliance with legal requirements, such as filing deadlines and the potential consequences of false statements. By understanding the various components and requirements of the WC-14 form, employees can better navigate the complexities of the workers' compensation system in Georgia.

Georgia Wc 14 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)

Download Georgia Wc 14

Document Breakdown

Fact Name	Details
Purpose	The WC-14 form serves as a Notice of Claim for workers' compensation in Georgia, allowing employees to notify the State Board of Workers' Compensation about their claims.
Options	Users can check one of three options: Notice of Claim Only, Request Hearing/Notice of Claim, or Request for Mediation/Notice of Claim.
Additional Information	If additional employers or insurers need to be added, a new WC-14 form must be completed. Do not alter the existing form; instead, attach extra sheets as necessary.
Submission Requirements	The form must be typed or printed in black ink to ensure clarity and compliance with submission standards.
Governing Laws	Key governing laws include O.C.G.A. §34-9-18, §34-9-19, and §34-9-100, which outline penalties for false statements and the dismissal of claims after five years without a hearing.
Certification	The form includes an affirmation section where the filing party attests to the accuracy of the information provided, acknowledging the potential penalties for false information.

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