Fill and Sign the 497303654 Form

Case No. or SS No.      (if applicable)       Name of Employee       County of Case       Assigned Division Attorney:       Phone:       Name:       Individual Sole Proprietor Corporate Officer Registered Agent Partner *Other Address:                   County:       Phone:       *       Name:       Address:             Phone:       (Affidavit Attached) Determination of possible civil penalties pursuant to the following code section(s): GEORGIA STATE BOARD OF WORKERS' COMPENSATION FRAUD AND COMPLIANCE REQUEST FOR HEARING OR TRIAL DIVISION INTERVENTION A . IDENTIFYING INFORMATION COMPLAINANTState Board of Workers' Compensation Fraud & Compliance Division 270 Peachtree Street, N.W. Atlanta, Georgia 30303-1299 Date of Injury (if applicable) RESPONDENT RESPONDENT'S ATTORNEY/ REGISTERED AGENT B. TYPE OF ACTION REQUESTED Hearing Order C. ISSUES TO BE DETERMINED ARE AS FOLLOWS: Determination of compliance of the above-named Respondent with the coverage requirements of O.C.G.A. §34-9-121 and/or O.C.G.A. §34-9-126. O.C.G.A. §34-9-18(a) Disregard of Board Orders or violation of Board Rules; $100.00 - $1,000.00 penalty. 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). Fraud and Compliance 24 Request for Hearing or Trial Form WC-24 Rev. Date 7/99 Division Intervention Other:             Action Requested by:       Date:                                     O.C.G.A. §34-9-18(b) Knowingly and intentionally makes any false or misleading statements or representations to facilitate the obtaining or denying of any benefits; $ 1,000. 00 - $1 0,000. 00 penalty. O.C.G.A. §34-9-18(c) Failure to comply with insurance requirements of the workers' compensation law or qualify as a self-insurer; $500.00 - $5,000.00 penalty. D. BRIEFLY DESCRIBE THE CIRCUMSTANCE SERVING AS THE BASIS OF YOUR REQUEST: (If requesting an Administrative Order, attach an affidavit) E. CERTIFICATION I hereby certify that the above is true and correct to the best of my knowledge. I have, this day, sent a copy of this to the above-named Respondent, Respondent's attorney or, to the Registered Agent if incorporated at the address listed above. SIGNATUR E PRINT NAME HERE ATTORNEY BAR NO. PHONE DATE Fraud and Compliance 24 Request for Hearing or Trial Form WC-24 Rev. Date 7/99 Division Intervention