Fill and Sign the Injury Workers Compensation 497303537 Form

sic Date of Birth Sex County of Injury Employer Aware Nature Body Part Cause M.O. Controvert D. First Yes No Yes No                                                                                                                                                                                                                                                                                                                          No Treatment Minor: By Employer Minor: Clinic/HospitalEmergency 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 Temporary partial disability Permanent partial disability of                          OSHA File GEORGIA STATE BOARD OF WORKERS' COMPENSATION EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE No. A. Insurer FileNo. Employer Employer Phone No. Insurer/Self Insurer Name TPA/Claims Office Address Employer FEIN TPA FEIN City State/Zip Nature of Business (Mfg., Trade, Transp., Etc.) Address Employer Location Address (If Different) City State/Zip City State/Zip Place of Accident or Exposure (Address or Location) Occupation TPA/Claims Office Phone No. Employee Name (Last) (First) (Middle) Date of Birth County of Injury Address Date of Injury Employee Social Security Number City State/Zip Employee's Home Ph. # Number of Dependents Including Spouse DO NOT WRITE INTHIS COLUMN Male Female Time of Injury Time Workday Began Date Employer Notified Insurer No. Date Hired Did Employee Work the Next Day? First Date Employee Failedto Work a Full Day Did Employee Receive FullPay 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 Yes No How 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) Position Telephone 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: % to for weeks Part of Body UNTIL WHEN 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 1 EMPLOYER'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 EARNINGSGross Week (Year) No. of Week Amount Paid No. Days Including Value of Additional Compensation Total From T o Worke d Overtime or Earnings Date Date Extra Work Meal s Lodging Ren t Tips All Other 1 2 3 4 5 6 7 8 9 10 11 12 13 Total Average 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 or self-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 1-800-533-0682In Atlanta, (404) 656-3818 FORM WC- I REV. DATE 7/2000 1 EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE