Fill and Sign the Georgia Workers Compensation Forms Form Perkins Studdard

WC -121 CHANGE OF TPA / SERVICING AGENT GEORGIA STATE BOARD OF WORKERS' COMPENSATION NOTICE OF CHANGE OF TPA / SERVICING AGENT The purpose of this form is to notify the Board of a change in the TPA/Servicing A gent. This form must be completed by the Insurer, Self -Insurer or G roup Fund no later than 30 days prior to the effective date of t he change and sent to the State Board of Workers’ Compensation, 270 Peachtree Street NW, Atlanta, GA 30303- 1299. A TP A / Servicing Agent MUST be licensed by the Office of the Commissioner of Insurance pursuant to O.C.G.A. !33- 23-100. A. INSURE R/SELF -INSUR ER/GROUP FUND FEIN # SBW C ID # Name of Insurer / Self -Insurer / Group Fund Mailing Address City State Zip Code Person Completing this Form Name of Company Signature of Person Completing this Form Date Phone Number and Ext E-mail address B. NOTICE OF TERMINATION TPA / Servicing Agent being Terminated FEIN # Mailing Address City State Zip Code C. NOTICE OF REPLACEMENT New TPA / Servicing Agent FEIN # Mailing Address City State Zip Code Contact Name Title Telep hone Number Fax Nu mber (toll-free if out -of-State of Georgia) E-mail Address Secondary E -mai l Effective Date of Change D. NOTICE OF ADDITION The above -named I nsurer / Self -Insurer / Group F und has OBTAINED the services of the following in dividual, firm, or company, as an additional TPA/ Servicing Agent for the administration of workers’ compensation claims . Na me of Additional TPA/ Servicing Agent FEIN # Mailing Address City State Zip Code Contact Name Title Telephone Number Fax N umber (toll-free if out -of-State of Georgia) E-mail Address Secondary E -mai l Effective Date of Change 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 PENALTIES OF UP TO $10, 000.00 PER VIOLATION (O.C.G.A. !34-9 -18 AND ! 34-9-19). WC-121 REVISION 7 /201 4 121 CHANGE OF TPA / SERVICING AGENT WC -121 CHANGE OF TPA / SERVICING AGENT GEORGIA STATE BOARD OF WORKERS' COMPENSATION Complete section A, B and C to notify the Board when a claims office /claims office address is being terminated and replaced. Complete s ection A and D to notify Board when an additional claims office /claims office address is being added. Complete section A, B C and D to notify Board when a claims office is being terminated, replaced and an additional claims office is being added. Sectio n A Insurer/Self -Insurer/Group Fund (all fields are mandatory in section A) 1. FEIN number for the insurer/self -insurer/group fund 2. SBWC ID number (five digit number) – (Not the five digit NACI number) see our website www.sbwc.georgia.gov/sbwc -id to verify your number 3. Name of insurer/self -insurer/group fund (do not use acronyms) 4. Mailing address, city, state, zip code 5. Person completing this form 6. Name of company 7. Signature of person co mpleting this form 8. Date the form is being completed 9. Phone number and extension 10. E-mail address – this will be used by the Board for notifications /legal notices and may be given to the public Section B Notice of Termination (mandatory when comp leting section C) 1. Name of claims office being terminated 2. FEIN # of the claims office being terminated 3. Mailing address, city, state, zip code of the claims office being terminated Section C Notice of Replacement (mandatory when completing secti on B) 1. Name of the claims office replacing the claims office in Section B 2. FEIN number of the claims office 3. Mailing address, city, state and zip code of the office that will handling the claims - this is the address that will be used by the Boar d for notifications 4. Contact name/title – this is the person the Board will contact if needed 5. Telephone number – this should be a local or a toll free number (remember this is the contact phone number given to the public) 6. Fax number 7. E-mail a ddress – this will be used by the Board for notifications /legal notices and will be given to the public 8. Secondary e -mail – if applicable 9. Effective date of the change implemented Section D Notice of Additional Claims Office 1. Name of the claims o ffice being added to list of authorized claims offices for the insurer/self - insurer/group fund 2. FEIN number 3. Mailing address, city, state and zip code – this is the address that will be used by the Board for notifications 4. Contact name/title – this is the person the Board will contact if needed 5. Telephone number – this should be a local or a toll free number (remember this is the contact phone number given to the public) 6. Fax number 7. E-mail address – this will be used by the Board for no tifi cations /legal notices and given to the public 8. Secondary e -mail – if applicable 9. Effective date of the change implemented 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 PENALTIES OF UP TO $10, 000.00 PER VIOLATION (O.C.G.A. !34-9 -18 AND ! 34-9-19). WC-121 REVISION 7 /201 4 121 CHANGE OF TPA / SERVICING AGENT