Fill and Sign the Georgia Workers Compensation Form

                                                                                               GEORGIA STATE BOARD OF WORKERS' COMPENSATION CONSOLIDATED YEARLY REPORT OF MEDICAL ONLY CASES NOTE: INSURERS GIVE COMPANY NAME. SELF-INSURERS AND GROUP SELF-INSURERS USE NAME AS IT APPEARS ON SELF-INSURANCE PERMIT. FOR BOARD USE ONLY NAME OF INSURER, SELF-INSURER, OR GROUP SELF-INSURER AS CERTIFIED BY THE STATE BOARD OF WORKERS' COMPENSATION IT IS THE RESPONSIBILITY OF THE INSURER OR SELF-INSURER TO CONSOLIDATE ALL INDIVIDUAL TPA AND CLAIMS OFFICE REPORTS INTO ONE REPORT AND SUBMIT YEARLY TO THE STATE BOARD OF WORKERS' COMPENSATION. THE TOTAL NUMBER OF CASES AND TOTAL MONEY REPORTED IS FOR A CALENDAR YEAR JANUARY 1 st TO DECEMBER 31st . FILE ANNUALLY EVEN IF NO REPORTABLE INJURIES OR PAYMENTS OCCURRED DURING THE REPORTING YEAR. FOR ALL MEDICAL EXPENSES, EXCEPT EMPLOYERS UTILIZING A WC/MCO, PLEASE REPORT THE TOTAL YEARLY MEDICAL EXPENSES BELOW: TOTAL NUMBER OF MEDICAL ONLY INJURIES THIS PERIOD. TOTAL AMOUNT PAID, MEDICAL ONLY THIS PERIOD. IF AN EMPLOYER IS UTILIZING A CERTIFIED WORKERS' COMPENSATION MANAGED CARE ORGANIZATION (WC/MCO), PLEASE REPORT THE TOTAL YEARLY MEDICAL EXPENSES BELOW: TOTAL NUMBER OF MEDICAL ONLY INJURIES THIS PERIOD. TOTAL AMOUNT PAID, MEDICAL ONLY THIS PERIOD. I CERTIFY TO THE BEST OF MY KNOWLEDGE THE TOTAL PAYMENTS SHOWN HAVE NOT BEEN REPORTED AS LOST TIME MEDICAL ON A FORM WC-4. By (Type or Print Name) Phone Number Date Address of Submitting Office REPORTING YEAR File on or before January 31st following each calendar year.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). 26 FORM WC-26 REV. DATE 7/2000 CONSOLIDATED YEARLY REPORT OF MEDICAL ONLY CASES