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Article Structure

Common mistakes

  1. Failing to provide complete identifying information. Ensure all fields, such as Employee Last Name, First Name, and Date of Injury, are filled out accurately.

  2. Not including the correct Board Claim Number. This number is essential for tracking the claim.

  3. Leaving out the Employer's Mailing Address. This information is crucial for proper notification.

  4. Using an incorrect or outdated Insurer/Self-Insurer File Number. Double-check this number to avoid delays.

  5. Neglecting to specify the grounds for controverting the claim. Clearly state the reasons in Section B.

  6. Failing to certify that a copy of the notice was sent to all relevant parties. This includes the employee and any other person with a financial interest.

  7. Not signing and dating the form. A signature is required to validate the document.

  8. Overlooking the need to file the form within the specified timeframe. The notice must be filed within 21 days of knowledge of the injury.

  9. Using the wrong form for the situation. Ensure you are using the WC-3 form specifically for controverting claims.

  10. Not keeping a copy of the completed form for personal records. This can be helpful for future reference.

Essential Points on This Form

What is the Georgia WC-3 form?

The Georgia WC-3 form, also known as the Notice to Controvert, is a document used in the workers' compensation process. It serves as a formal notice from an employer or insurer to the State Board of Workers' Compensation indicating that they are disputing a claim for compensation. This form outlines the specific reasons for the controversion and must be filed within a certain timeframe after the employer becomes aware of the injury.

When must the WC-3 form be filed?

The WC-3 form must be filed with the State Board of Workers' Compensation within 21 days after the employer learns about the injury or death. This timely filing is crucial to ensure that the employer or insurer does not face penalties, such as the assessment of attorney's fees.

Who needs to receive a copy of the WC-3 form?

A copy of the WC-3 form must be sent to the employee or claimant, all legal counsel involved, and any other individuals who have a financial interest in the claim. This ensures that all relevant parties are informed about the controversion.

What information is required on the WC-3 form?

The WC-3 form requires identifying information about the employee, employer, and insurer or self-insurer. It also includes sections for detailing the specific grounds for the controversion, whether it concerns the right to compensation or the compensability of medical treatment. Accurate completion of these sections is essential for the form to be valid.

Can the WC-3 form be used to suspend benefits?

No, the WC-3 form cannot be used to suspend benefits if the only issue is the length of disability. In such cases, a different form, the WC-2, should be filed. However, if liability is denied after compensation has begun, the WC-3 form may still be used within the appropriate timeframe.

What should an employee do if they disagree with the controversion?

If an employee disagrees with the reasons stated in the WC-3 form, they can request a hearing. This is done by submitting a Form WC-14 to the State Board of Workers' Compensation. The employee can obtain this form by contacting the Board directly or visiting their website.

What are the consequences of providing false information on the WC-3 form?

Providing false information on the WC-3 form is considered a crime. Penalties can reach up to $10,000 for each violation. It is important to ensure that all information submitted is accurate and truthful to avoid legal repercussions.

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Georgia Wc 3 Sample

WC-3 NOTICE TO CONTROVERT

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

NOTICE TO CONTROVERT

Board Claim No.

Employee Last Name

Employee First Name

M.I.

Date of Injury

 

 

 

 

A. IDENTIFYING INFORMATION

 

 

 

 

 

EMPLOYEE

 

Mailing Address

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee E-mail Address

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER

 

Name

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

Employer E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURER/

 

Name

 

 

Insurer/Self-Insurer File #

 

 

 

 

 

 

 

 

 

SELF-INSURER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIMS

 

Name

 

 

Claims Office E-mail

 

 

 

 

 

 

 

 

 

 

 

OFFICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SBWC ID

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

B. CONTROVERT TYPES

1. This serves as notice, pursuant to O.C.G.A. §34-9-221, that the right to compensation in this claim is being controverted on the following

 

specific grounds:

 

 

 

2.

This is notice, pursuant to O.C.G.A. §34-9-200 and Board Rule 205(b), that the compensability of the following medical treatment / test is

 

 

being controverted for the following specific reasons:

 

 

 

3.

If only part of the claim is being controverted, state the specific part of the claim and the reason(s) it is being controverted:

 

 

 

 

 

C. CERTIFICATE OF SERVICE

 

 

This is to certify that a copy of both sides of this notice has been sent to the employee / claimant(s), all counsel of record and any other person with

 

a financial interest, as listed below:

 

 

 

 

 

 

 

 

 

 

 

 

 

Type or Print Name

 

Signature

 

Date

 

 

 

 

 

Phone Number

 

E-mail Address

 

 

 

 

This form must be filed with the State Board of Workers' Compensation. A copy of both sides of this form must be given to the employee and any other

person with a financial interest in the claim including, but not limited to the employer, medical care provider(s) and attorney(s).

 

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-3

REVISION 12/2018

3

NOTICE TO CONTROVERT

 

 

 

1 OF 2

 

 

WC-3

NOTICE TO CONTROVERT

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

INFORMATION FOR THE INSURER/SELF-INSURER:

Board Rule 61(b)(1): An insurer who receives a Form WC-1 from an employer shall clearly stamp the date of receipt on the form, review Section A, and complete any unanswered questions. The insurer shall complete either Section B or Section C or Section D and, by the 21st day following the employer's knowledge of disability, forward the original to the Board and a copy to the employee.

Board Rule 61(b)(4): previously been filed. 9-221 and Rule 221.

Form WC-3. Notice to Controvert Payment of Compensation. Complete Form WC-3 to controvert when a Form WC-1 has Furnish copies to employee and any other person with a financial interest in the claim. See subsections (d), (h), and (i) of Code §34-

O.C.G.A. §34-9-221(d): If the employer controverts the right of compensation, it shall file with the Board, on or before the twenty-first day after knowledge of the alleged injury or death, a notice in accordance with the form prescribed by the Board, stating that the right of compensation is controverted and stating the name of the claimant, the name of the employer, the date of the alleged injury or death, and the ground upon which the right to compensation is controverted.

Board Rule 221(d): To controvert in whole or in part the right to income benefits or other compensation use Form WC-1 or WC-3. Failure to file the Forms WC-1 or WC-3 before the 21st day after knowledge of the injury or death may subject the employer/insurer to assessment of attorney's fees. See O.C.G.A. §34-9-108(b)(2)(3).

O.C.G.A. §34-9-221(h): When compensation is being paid without an award, the right to compensation shall not be controverted except upon the grounds of change in condition or newly discovered evidence unless a notice to controvert is filed with the Board within 60 days of the due date of first payment of compensation.

Board Rule 221(h)(1): A Form WC-3 shall not be used to suspend benefits if the only issue is length of disability. In these cases, suspend benefits by filing a Form WC-2 or follow the procedure outlined in Rule 240. If liability is denied subsequent to commencement of payment, but within 60 days of due date of first payment of compensation, file Form WC-3 in addition.

O.C.G.A. §34-9-221(i): When compensation is being paid with or without an award and an employer or insurer elects to controvert on the grounds of a change in condition or newly discovered evidence, the employer shall, not later than 10 days prior to the due date of the first omitted payment of income benefits, file with the Board and the employee or beneficiary a notice to controvert the claim in a manner prescribed by the Board.

Board Rule 221(h)(2): If income benefits have been continued for more than 60 days after the due date of first payment of compensation, benefits may be suspended only on the grounds of a change in condition or newly discovered evidence. File Forms WC-2 or WC-2(a). When controverting a claim based on newly discovered evidence, file Form WC-3 also.

O.C.G.A. §34-9-108(b)(2): If any provision of Code Section §34-9-221, without reasonable grounds, is not complied with and a claimant engages the services of an attorney to enforce rights under that Code Section and the claimant prevails, the reasonable fee of the attorney, as determined by the Board, and the costs of the proceedings may be assessed against the employer.

INFORMATION FOR THE EMPLOYEE:

This claim is being controverted for the reason(s) indicated on the front of this form. If you disagree, you should request a hearing by sending Form WC-14 to the State Board of Workers’ Compensation at the address below. If you need a Form WC-14, please contact the State Board of Workers’ Compensation at the phone numbers listed below or visit the website.

STATE BOARD OF WORKERS' COMPENSATION

270 Peachtree Street, N.W. Atlanta, Georgia 30303-1299 In Atlanta: 404-656-3818

or: 1-800-533-0682

http://www.sbwc.georgia.gov

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-3

REVISION 12/2018

3

NOTICE TO CONTROVERT

 

 

2 OF 2

 

Key takeaways

When dealing with the Georgia WC-3 form, understanding its purpose and requirements is essential for both employees and employers. Here are some key takeaways to keep in mind:

  • Purpose of the Form: The WC-3 form serves as a notice to controvert a claim for workers' compensation benefits. It is used when an employer or insurer disputes the right to compensation for an injury or medical treatment.
  • Filing Timeline: The form must be filed with the State Board of Workers' Compensation within 21 days after the employer becomes aware of the injury. Timely submission is crucial to avoid penalties.
  • Information Required: Complete all sections of the form, including identifying information for the employee, employer, and insurer. Clear details about the grounds for controverting the claim are necessary.
  • Distribution of Copies: After filing, a copy of the WC-3 form must be provided to the employee and any other parties with a financial interest in the claim. This ensures all involved parties are informed.
  • Consequences of False Statements: Be aware that intentionally providing false information on the form can lead to serious legal penalties, including fines. Honesty is essential when filling out the WC-3.

Understanding these aspects can help navigate the complexities of workers' compensation claims in Georgia effectively.

Document Characteristics

Fact Name Description
Purpose The WC-3 form serves as a notice to controvert a worker's compensation claim in Georgia.
Governing Law This form is governed by O.C.G.A. §34-9-221 and Board Rule 205(b).
Filing Deadline The notice must be filed within 21 days of the employer's knowledge of the injury.
Contents It requires identifying information about the employee, employer, and insurer.
Controvert Types Employers can controvert compensation rights based on specific grounds listed in the form.
Certificate of Service A certification section confirms that all relevant parties have received a copy of the notice.
False Statements Willfully making false statements can lead to penalties up to $10,000, as per O.C.G.A. §34-9-18.
Employee Rights Employees can contest the controversion by filing Form WC-14 if they disagree.
Contact Information For questions, contact the State Board of Workers' Compensation at 404-656-3818.