Fill and Sign the Motionobjection to Motion Form

WC-102 D MOTION / OBJECTION TO MOTION GEORGIA STATE BOARD OF WORKERS' COMPENSATION 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 OBTAININ G 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 -102 D REVISION 07/2017 102D MOTION / OBJECTION TO MOTION MOTION / OBJECTION TO MOTION  Motion  Objection to Motion When you receive this completed form, you may file a res ponse with the Board within fifteen (15) days of the date of the certificate of service (O.C.G.A. §9- 11-6 (e)) All responses must be filed on Form WC-102D. Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION EMPLOYEE County of Injury Address E-mail Address City State Zip Code EMPLOYER Name INSURER / SELF-INSURER Name Address CLAIMS OFFICE Name Address City State Zip Code City State Zip Code Employer E-mail Claims E-mail ATTORNEY FOR EMPLOYEE / CLAIMANT Name ATTORNEY FOR EMPLOYER / INSURER Name Address Address City State Zip Code City State Zip Code GA Bar Number GA Bar Number Attorney E-mail Attorney E-mail B. ACTION REQUESTED  1. This MOTION is being requested by  Employee  Employer/Insurer  Other Party The purpose of this motion is to request: (Arguments and documentation in support of this motion are attach ed.)  2. This OBJECTION is being submitted by  Employee  Employer/Insurer  Other Party The purpose of this objection is to request: (Arguments and documentation in support of this objection are attach ed.) C. ENTRY OF APPEARANCE  I hereby certify to the existence of a valid fee contr act in compliance with Board Rule 108 or a Form WC- 102B in compliance with Board Rule 102 (fee contract or WC- 102B has been previously filed or is attached). D. CERTIFICATE OF SERVICE  I hereby certify that the parties have made a good fai th effort to reach agreement on this issue, but have failed to do so to date. I further certify that I have this day sent a copy o f this form with supporting documentation to the State Boa rd of Workers’ Compensation, 270 Peachtree St., NW, Atlanta, GA 30303- 1299 and to all parties and counsel in this claim. Print Name Here Signature Phone Number E-mail Address Date