Fill and Sign the Full Text of Ampquotno Fault Motor Vehicle Insurance Hearings Form

sicDate of Birth SexCounty of Injury Employer Aware NatureBody Part CauseM.O.ControvertD. FirstYesNoYesNo %% % %% % %% % % No Treatment Minor: By Employer Minor: Clinic/Hospital Emergency Care Hospitalized > 24 hrs. No Average weekly wage: $ Weekly benefit: $ Date of disability: Compensation paid: $ Penalty paid: $ No BENEFITS ARE PAYABLE FROM Total/temporary total disability Temporary partial disability Permanent partial disability of % OSHA FileGEORGIA STATE BOARD OF WORKERS' COMPENSATION EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE No.A.Insurer File No.EmployerEmployer Phone No. Insurer/Self Insurer Name TPA/Claims Office AddressEmployer FEIN TPA FEIN CityState/ZipNature of Business (Mfg., Trade, Transp., Etc.) AddressEmployer Location Address (If Different) CityState/ZipCityState/ZipPlace of Accident or Exposure (Address or Location) OccupationTPA/Claims Office Phone No. Employee Name (Last) (First) (Middle) Date of Birth County of Injury AddressDate of Injury Employee Social Security Number CityState/ZipEmployee's Home Ph. # Number of Dependents Including Spouse DO NOT WRITE IN THIS COLUMN MaleFemaleTime of Injury Time Workday Began Date Employer Notified Insurer No. Date Hired Did Employee Work the Next Day? First Date Employee Failed to Work a Full Day Did Employee Receive Full Pay for Date of Injury? Hours Worked Number of Days List Normally Scheduled Wage Rate at Time of Injury or Disease Per Day Worked Per Off Days Hour Day Per Week Week ( )Week Mo. COMPLETE WAGE STATEMENT ON REVERSE: If employee is paid hourly, on commission or piecework basis, enter average weekly amount If board, lodging, or other advantages were furnished, enter average weekly amount $$Did Injury/Illness Exposure Occur on Employer's Premises? Type of Injury/Illness Part of Body Affected YesNoHow Injury or Illness/Abnormal Health Condition Occurred. If Returned to Work, Give Date Returned at What Wage If Fatal: Give Date of Death per Week Treating Physician (Name and Address) Initial Treatment Hospital (Name & Address) MCO Yes Report Prepared By (Print or Type) PositionTelephone Number Date of Report EMPLOYER'S FAILURE TO SUBMIT THIS REPORT TO INSURER IMMEDIATELY MAY RESULT IN PENALTY B.FOR USE BY INSURER/SELF-INSURER Date of first payment: Previously Medical Only Yes FOR:% toforweeksPart of BodyUNTILWHEN THE EMPLOYEE ACTUALLY RETURNED TO WORK. ALL OTHER SUSPENSIONS REQUIRE THE FILING OF FORM WC2 WITH THE STATE BOARD OF WORKERS' COMPENSATION AND THE EMPLOYEE. By(Insurer/Self Insurer: Type or Print Name of Person Filing Form and Sign) (Date)(Phone)(Extension)NOTICE TO CONTROVERT PAYMENT OF COMPENSATION (over for additional information) Benefits will not be paid because: By(Insurer/Self Insurer: Type or Print Name of Person Filing Form and Sign) (Date)(Phone)(Extension)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). FORM WC- I REV. DATE 7/2000 1EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE write the name of the similar employee here: ADDITIONAL INFORMATION WHEN CONTROVERTING: Complete the schedule below for thirteen (13) weeks immediately preceding the accident. If the employee has not been in your employ for thirteen (13) weeks, complete this schedule showing gross weekly earnings of a similar employee in the same employment, and Also use to establish wage loss for temporary partial disability payments. WAGE STATEMENT SCHEDULE OF WEEKLY EARNINGS GrossWeek(Year)No. ofWeekAmount Paid No.DaysIncludingValue of Additional Compensation TotalFromT o WorkedOvertime or EarningsDateDateExtra Work MealsLodgingRentTipsAll Other 12345678910111213TotalAverage Weekly Earnings NOTICE TO EMPLOYER 1. Provide prompt medical attention; allow the employee to select a physician from your posted panel, and explain the panel to the employee.2. Complete Section A of this form immediately upon your knowledge of an injury, and send the WC-1 to your insurance company orself-insurer claims office. FAILURE TO DO SO MAY RESULT IN A PENALTY . Do not send this form to the State Board of Workers' Compensation. 3. If you need additional help, call your insurance company or self-insurer claims office. 4. Report serious injuries immediately by telephone to your insurer's claims department, then file this form with your insurance company or self-insurer claims office. NOTICE TO EMPLOYEE 1. This form is provided for your information only: If Section B is completed, you will receive income benefits on a weekly basis and the employer will pay medical expenses through approved doctors. If you do not receive payment of benefits, or medical bills are not paid, call your employer or your employer's insurance company or self-insurer claims office. If Section C is completed, your claim of injury has been denied by the employer/insurer. If you disagree with this denial, you must file a form WC-14, Notice of Claim, within one year of the accident with the State Board of Workers' Compensation, 270 Peachtree Street N.W., Atlanta, Georgia 30303- 1299.For Information or Assistance contact the: STATE BOARD OF WORKERS' COMPENSATION; Toll Free Telephone 1-800-533-0682 In Atlanta, (404) 656-3818 FORM WC- I REV. DATE 7/2000 1EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE