Fill and Sign the Notice of Claim State Board of Workers Compensation Form

WC -14 NOTICE OF CLAIM 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 OBTAINING OR DEN YING 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 -14 REVISION 0 2/2016 14 NOTICE OF CLAIM For injuries occurring on or after July 1, 2007, any claim filed with the Board for which neither medical nor income benefits have been paid shall stand dismissed with prejudice by operation of law if no hearing has been held within five years of the alleged date of in jury. (O.C.G.A. §34-9-100) Check only one : 2 NOTICE OF CLAIM ONLY 2 REQUEST HEARING / NOTICE OF CLAIM 2 REQUEST FOR MEDIATION / NOTICE OF CLAIM Complete a new Form WC -14 to add an additional employer, insurer or to add date of injury. If you need additional space, do not alter this form, but instead attach addit ional sheets. Must be typed or printed in black ink. Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. CLAIM INFORMATION EMPLOYEE Birthdate County of Injury Address Employee E -mai l City State Zip Code EMPLOYER Na me INSURER/ SELF- INSURER Na me SBW C# (five digit #) Address Address City State Zip Code City State Zip Code Employer E -mai l Insurer E-mail ATTORNEY FOR EMPLOYEE/CLAIMANT Na me ATTORNEY FOR EMPLOYER/INSURER Na me Address GA Bar Number Address GA Bar Number City State Zip Code City State Zip Code Attorney E -mai l Attorney E -mai l 1. Part of Body Injured 2. First Date Disabled 3. If Fatal – Enter complete date of death Claimants for death benefits (list names & addresses) attach additional sheets 4. Description of Accident B. HEARING / MEDIATION ISSUES 2 Income Benefits 2 TTD(Dates) 2 Medical Benefits List Benefits: 2 TPD(Dates) 2 PPD(Dates) 2 Suspension / Termination Request Effective Date 2Dependency Benefits 2 Burial Expenses Reason: 2 Penalties / Assessed Attorney Fees 2 §34-9- 221e 2 §34-9- 108b (1) 2 §34-9- 108b(2) 2 Other 2Request for Catastrophic Designation Specify: 2 Appeal of Rehabilitation Decision Specify: 2 Other Hearing Issues Specify: Additional Board Claim Numbers which will be involved (if any): 2 (Complete a separate form W C14 for each date of accident) C. AFFIRMATION OF FILING PARTY 2 I, [the person whose name appears above], attest and affirm that all information contained herein is true and correct to the best of my knowledge. I understand that knowingly giving false information to obtain or deny workers’ compensation benefits subjects me to civil and criminal penalties. D. ENTRY OF APPEARANCE 2 I hereby certify to the existence of a valid fee contract in compliance with Board Rule 108 or a Form W C-102B in compliance with Board Rule 102. (fee contract or W C -102B has been previously filed or is attached) E. CERTIFICATE OF SERVICE 2 I hereby certify that I have today sent a copy of this form to all of the par ties and have sent this form to the State Board of W orkers' Compensation, 270 Peachtree St., NW , Atlanta, Georgia 30303 -1299. Print Name Signature Date Phone Number E-mai l