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Fill a Valid Georgia Wc 14 Template

The Georgia WC-14 form serves as a formal notice of claim for workers' compensation cases in the state of Georgia. This document can be used to request a hearing, mediation, or simply to notify the State Board of Workers' Compensation about a claim. Accurate completion of the form is essential for proper processing and to ensure compliance with relevant regulations.

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Article Structure

Common mistakes

Incomplete Information: Failing to fill out all required fields can lead to delays. Ensure that every section is completed, including personal details and specifics about the injury.
Incorrect Dates: Entering the wrong date of injury or first date disabled can complicate the claim process. Double-check these dates for accuracy.
Not Attaching Additional Sheets: If more space is needed for descriptions or additional employers, do not alter the form. Instead, attach extra sheets as specified.
Using Incorrect Ink: The form must be typed or printed in black ink. Using other colors can result in rejection of the form.
Missing Signatures: Ensure that the form is signed by the appropriate parties. A missing signature can invalidate the submission.
Failure to Notify All Parties: Not sending copies of the form to all required parties can lead to disputes later. Keep a record of all notifications.
Ignoring Deadlines: Be aware of filing deadlines. Late submissions can result in the dismissal of the claim.

Essential Points on This Form

What is the purpose of the Georgia WC-14 form?

The Georgia WC-14 form is used to notify the State Board of Workers' Compensation about a claim for workers' compensation benefits. It allows employees to file a claim, request a hearing, or seek mediation regarding their workplace injuries. This form helps ensure that all necessary parties are informed and that the claim is processed efficiently.

Who needs to fill out the WC-14 form?

The WC-14 form must be completed by employees who have suffered a work-related injury or illness and wish to claim benefits. Employers or insurers may also need to fill it out if they are involved in the claim process, especially if there are disputes or requests for hearings or mediation.

What information is required on the WC-14 form?

Essential information includes the employee's name, date of injury, and details about the injury itself. You will also need to provide information about the employer and insurer, including their names and addresses. If applicable, details about any legal representation should be included as well.

How do I submit the WC-14 form?

The completed WC-14 form must be sent to the State Board of Workers' Compensation at the specified address: 270 Peachtree St., NW, Atlanta, Georgia 30303-1299. It is crucial to ensure that all parties involved receive a copy of the form, as indicated in the Certificate of Service section.

What happens if I do not submit the WC-14 form on time?

If the WC-14 form is not submitted in a timely manner, you may risk losing your right to benefits. For claims filed for injuries occurring on or after July 1, 2007, if no hearing is held within five years of the injury date, the claim will be dismissed automatically. This emphasizes the importance of timely filing.

Can I add additional information to the WC-14 form?

If you require more space to provide information, do not alter the existing form. Instead, attach additional sheets with the necessary details. Make sure that all information is typed or printed clearly in black ink to avoid any confusion during processing.

What are the consequences of providing false information on the WC-14 form?

Providing false information on the WC-14 form can lead to serious legal consequences. It is considered a crime and may result in civil and criminal penalties, including fines of up to $10,000 per violation. It is essential to ensure that all information is accurate and truthful to avoid these repercussions.

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Georgia Wc 14 Sample

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)

Key takeaways

Here are some key takeaways about filling out and using the Georgia WC-14 form:

Purpose: The WC-14 form serves to notify the Georgia State Board of Workers' Compensation about a claim or request for a hearing or mediation.
Completion: Ensure the form is filled out in black ink, either typed or printed, to maintain clarity.
Multiple Claims: If you need to add additional employers or insurers, complete a new WC-14 form instead of altering the existing one.
Accurate Information: Provide accurate details about the employee, injury, and accident description to avoid issues later.
Signature Requirement: The form must be signed by the filing party, affirming that all information is true and correct.
Service Certification: You must certify that a copy of the form has been sent to all relevant parties and to the State Board.
Time Limit: Be aware of the five-year rule for claims; if no hearing is held within this timeframe, the claim may be dismissed automatically.

Document Characteristics

Fact Name	Details
Purpose	The WC-14 form is used to notify the Georgia State Board of Workers' Compensation of a claim for benefits related to workplace injuries.
Filing Options	Claimants can check one of three options: Notice of Claim Only, Request Hearing/Notice of Claim, or Request for Mediation/Notice of Claim.
Additional Information	To add an additional employer, insurer, or date of injury, a new WC-14 form must be completed. Additional sheets may be attached if necessary.
Governing Law	The form is governed by Georgia law, specifically O.C.G.A. §34-9-100, which outlines the dismissal of claims if no hearing occurs within five years.
Certification	Filing parties must affirm that all information provided is true and correct, acknowledging the penalties for false statements.
Submission Requirements	The completed form must be sent to the State Board of Workers' Compensation at their Atlanta office, and a copy must be provided to all involved parties.