Fill and Sign the Georgia Suspension Form

CommenceSuspend Amend the WC- I/WC-2a dated                           Part A Below/ Part B Below                                                                                                                     Benefits will be paid at the rate of $       * per week based on an average weekly wage of $       payable from       The date of the first check is       I the amount is $       does not/ does include a       % penalty in the amount of $                                       BENEFITS WILL BE SUSPENDED ON             By                   GEORGIA STATE BOARD OF WORKERS' COMPENSATION NOTICE OF PAYMENT OR SUSPENSION OF DEATH BENEFITS Insurer File Number/ / as indicated in Deceased Employee's Social Security Number Deceased Employee's Name (First) (Middle) (Last) Date of Injury Deceased Employee's Street Address Cit y State Zip Employer Insurer Address Address City State Zip Phone Cit y State Zip Phon e A- I I and this The date of death was / / * File Form WC-6, Wage Statement, if weekly benefit is less than the maximum. Nam e TOTAL DEPENDENTS: (Use additional sheets if required.) Address/Telephone Number Date of Birth Relationship PARTIAL DEPENDENTS: (Complete only when there are no total dependents. Use additional sheets if required.) Date of Weekly Contribution Nam e Addres s Birth Relationship From Deceased B- Reason: (Type or Print and Sign) (Date) (Phone) The original of this form must be filed with the State Board of Workers' Compensation. A copy of both sides of this form must be given to the person receiving benefits when payments are started and when payments are stopped. 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). 2a FORM WC-2a REV. DATE 7/2000 NOTICE OF PAYMENT OR SUSPENSION OF DEATH BENEFITS A. OUTLINE OF BENEFITS O.C.G.A. §34-9-265: If an EMPLOYEE IS INJURED AT WORK AND DIES AS A RESULT, his or her DEPENDENTS receive: • Medical expenses for the deceased's last injury. • Up to $7,500.00 for funeral expenses. • 2/3 of the deceased's average weekly wage with a maximum of $350 per week for accidents on or after July 1, 1999, and a maximum of $375 per week for accidents on or after July 1, 2000. • A minimum of $37.50 per week, or the actual weekly wage if less than $37.50 per week. If the surviving spouse is or becomes the SOLE DEPENDENT within the first year following the death of the employee, the amount of weekly benefits the spouse alone will be entitled to is limited to $125,000. Compensation provided by this code section is PAYABLE ONLY TO DEPENDENTS and ONLY DURING DEPENDENCY. If there is MORE THAN ONE DEPENDENT, weekly benefits will be APPORTIONED AMONG THE DEPENDENTS. DEFINITION OF DEPENDENT O.C.G.A. §34-9-13: The following are some of the persons who may receive benefits: A SURVIVING SPOUSE who had not voluntarily abandoned his/her spouse at the time of the accident resulting in death. Dependency shall terminate upon remarriage or cohabitation in a meretricious relationship. UNMARRIED CHILDREN (including stepchildren, adopted children, and posthumous children) under 18 years of age (under 22 if a full-time student in a post-secondary institution of higher learning) or incapable of self-support. PARTIAL DEPENDENTS - Persons partially dependent are eligible only if there are no total dependents. NO DEPENDENT DEATH CASES Rule 265: The insurer or self-insurer in no-dependency death cases, shall pay to the State Board of Workers' Compensation the amount set forth in Code Section 34-9-265(b). B. RIGHT TO HEARING If your benefits as a dependent have been suspended and you believe that benefits were suspended incorrectly, you should request a hearing by sending Form WC-14 to the State Board of Workers' Compensation at the address below. If you need a Form WC-14, write to the address below and ask for one to be mailed to you, or call 1-800- 533-0682 (in Atlanta, (404) 656-3870) for other claim assistance. STATE BOARD OF WORKERS' COMPENSATION 270 PEACHTREE STREET, N.W., ATLANTA, GEORGIA 30303-1299 2a FORM WC-2a REV. DATE 7/2000 NOTICE OF PAYMENT OR SUSPENSION OF DEATH BENEFITS