Fill and Sign the 61 Publication of Notice of Operation under the Act Forms

WC -4 CASE PROGRESS REPORT GEORGIA STATE BOARD OF WORKERS' COMPENSATION 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 -4 REVISION 07/201 7 4 CASE PROGRESS REPORT CASE PROGRESS REPORT (File per Board Rule 61(b)5) Check Only One:  Initial  Supplement al  Final  Reopened Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION EMPLOYER Name Insurer /Self Insurer File Number SBWC ID# (five digit no.) Date of Final Weekly Payment B. INDEMNITY PAYMENTS (enter actual amounts paid) RATE WEEKS DAYS TOTAL PAYMENTS  (a) Temporary Total  (b) Temporary Partial  (c) Permanent Partial  (d) Death  (e) Stipulation/Settlement  (f) Advances C. TOTAL PAYMENTS TO DATE 1 Total Indemnity 2 Physic ian 3 Hospital 4 Pharmacy 5 Physical Therapy 6 Chiropractic 7 Other (Medical) 8 Rehabilitation / Vocational (excluding all of the above) 9 Late Payment Penalties 10 Assessed Attorney's Fees 11 Burial Totals D. RECOVERY PAYMENTS Recovery code: for Subrogation for Overpayment for SITF Other Remarks E. CERTIFICATION I certify that the total payments are as correct as the available information indicates. Type or Print Name Signature Date Address E-mail City State Zip Code Phone Number Insurer/Self Insurer Name Claims Office Name