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Fill a Valid Georgia Wc 100 Template

The Georgia WC 100 form is a critical document used to request settlement mediation in workers' compensation cases within the state. This form facilitates communication between the involved parties, including the employee, employer, and their respective representatives, ensuring that all are prepared to negotiate a settlement. By filing this form, parties affirm their commitment to engage in mediation, aiming for a resolution that addresses the needs of all stakeholders involved.

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Article Structure

Common mistakes

Failing to provide complete identifying information. All fields, including names, addresses, and contact details, must be filled out accurately.
Incorrectly entering the Board Claim Number. Ensure that the correct claim number is used to avoid processing delays.
Not indicating whether the claim involves a catastrophic injury designation. This information is crucial for proper handling of the claim.
Omitting the employee's Social Security Number or Board Tracking Number. This information is essential for identification and processing.
Failing to certify participation in mediation. All parties must agree to participate in the mediation process.
Not providing the correct email addresses for all parties involved. Accurate email communication is vital for updates and notifications.
Neglecting to confirm the existence of a valid fee contract. This step is necessary to comply with Board rules.
Forgetting to send a copy of the form to all parties named. This ensures everyone is informed and can prepare for mediation.
Failing to include the signature and date for both the employee representative and the employer/insurer representative. Signatures validate the submission.
Not checking for any updates or changes to the form requirements. Always review the latest guidelines before submission.

Essential Points on This Form

What is the Georgia WC-100 form?

The Georgia WC-100 form is a request for settlement mediation related to workers' compensation claims. It is used by employees and employers to initiate a mediation process aimed at resolving disputes over claims. This form is submitted to the Georgia State Board of Workers' Compensation to facilitate discussions between the involved parties.

Who needs to fill out the WC-100 form?

What information is required on the WC-100 form?

What is the purpose of the mediation request?

How does one certify participation in mediation?

What happens after the form is submitted?

Are there penalties for false statements on the WC-100 form?

Where can I get more information about the WC-100 form?

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Georgia Wc 100 Sample

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

Key takeaways

When filling out and using the Georgia WC 100 form, keep these key takeaways in mind:

Accurate Information: Ensure all identifying information, including names, addresses, and contact details, is correct. Errors can delay the mediation process.
Certification Requirement: All parties must certify their agreement to participate in mediation and confirm that the employer/insurer has settlement authority. This is crucial for moving forward.
Documentation: If applicable, verify that the Subsequent Injury Trust Fund has been informed about the settlement conference and that all necessary documents are provided.
Submission Process: After completing the form, send copies to all parties involved and submit it to the State Board of Workers' Compensation promptly to avoid any potential issues.

Document Characteristics

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 (O.C.G.A. §34-9).
Claim Information	It requires specific claim information, including the Board Claim Number and details about the employee and employer.
Involved Parties	All parties involved must provide their contact information, including names, addresses, and emails.
Settlement Authority	Employers or insurers must certify that they have obtained settlement authority before mediation.
Certification Requirement	Filing the form certifies that all parties agree to participate in mediation.
Subsequent Injury Trust Fund	If applicable, the form must indicate whether the Subsequent Injury Trust Fund has been notified of the mediation.
Fee Contract	A valid fee contract must exist, in compliance with Board Rule 108 or Form WC 102B.
False Statements Penalty	Providing false information can lead to penalties of up to $10,000 per violation (O.C.G.A. §34-9-18 and §34-9-19).