Fill and Sign the Attorney Leave of Absence State Board of Workers Form

WC-102c ATTORNEY LEAVE OF ABSENCE 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 OBTAININ G 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-102c REVISION 07/2017 102c ATTORNEY LEAVE OF ABSENCE ATTORNEY LEAVE OF ABSENCE Complete this form, and send to the State Board of Workers’ Compensation, 270 Peachtree Street, N.W. , Atlanta, Georgia 30303-1299 I, (Attorney’s Name) Address City State Zip Code Attorney E-mail GA Bar Number Do hereby request that I be granted a leave of absence on cases in w hich I am counsel of record for the following period(s) o f time: / / through / / (month) (day) (year) (month) (day) (year) / / through / / (month) (day) (year) (month) (day) (year) / / through / / (month) (day) (year) (month) (day) (year) / / through / / (month) (day) (year) (month) (day) (year) / / through / / (month) (day) (year) (month) (day) (year) / / through / / (month) (day) (year) (month) (day) (year) / / through / / (month) (day) (year) (month) (day) (year) / / through / / (month) (day) (year) (month) (day) (year) / / through / / (month) (day) (year) (month) (day) (year) / / through / / (month) (day) (year) (month) (day) (year)