Fill and Sign the Employers First Report of Injury or Occupational Disease State Form

WC -3 NOTICE TO CONTROVERT 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 PENALTIE S OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34 -9-18 AND §34 -9-19). WC -3 REVISION 07/201 7 3 NOTICE TO CONTROVERT 1 OF 2 NOTICE TO CONTROVERT Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION EMPLOYEE Phone Number Address Employee E -mail Address City State Zip Code EMPLOYER Name Phone Number Address City State Zip Code Employer E -mail Address INSURER/ SELF -INSURER Name Insurer/Self -Insurer File # CLAIMS OFFICE Name Phone Number Address SBWC ID# (five digit no.) City State Zip Code Claims Office E -mail Address 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 recor d 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 th e 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). WC -3 NOTICE TO CONTROVERT 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 PENALTIE S OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34 -9-18 AND §34 -9-19). WC -3 REVISION 07/201 7 3 NOTICE TO CONTROVERT 2 OF 2 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 th e employer's knowledge of disability, forward the original to the Board and a copy to the employee. Board Rule 61(b)(4): Form WC -3. Notice to Controvert Payment of Compensation. Complete Form WC -3 to controvert when a Form WC -1 has previously been file d. Furnish copies to employee and any other person with a financial interest in the claim. See subsections (d), (h), and (i ) of Code !34- 9-221 and Rule 221. O.C.G.A. !34-9-221(d): If the employer controverts the right of compensation, it shall file wit h 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 compe nsation is controverted and stating the name of the claimant, the na me 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 fee s. See O.C.G.A. !34-9-108(b)(2)(3). O.C.G.A. !34-9-221(h): When compensation is being p aid 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 t he 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 filin g 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 contr overt 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 fir st omitted payment of income benefits, file with the Board and the employee or beneficiary a notice to co ntrovert 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 ma y be suspended only on the grounds of a change in c ondition 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 attorn ey, as determined by the Board, and the costs of the proceedings may be assessed again st 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 th e 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