Fill and Sign the Notice of Representation of Any Party Other Than a Claimant or Employee by an Attorney Form

WC-102b NOTICE OF REPRESENTATION OF ANY PARTY OTHER THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY 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-102b REVISION 07/20 17 102 b NOTICE OF REPRESENTATION OF ANY PARTY OTHER THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY NOTICE OF REPRESENTATION OF ANY PARTY OTHER THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY (This form is not to be filed by an attorney for claimant / employee) Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION EMPLOYEE Phone Number County of Injury EMPLOYER Name Address Address City State Zip Code City State Zip Code Employee E-mail Employer E-mail Phone Number INSURER / SELF-INSURER Name PARTY AT INTEREST OR SITF Name CLAIMS OFFICE Name Address Address City State Zip Code City State Zip Code Claims E-mail Phone Number Party E-mail Phone Number 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 Phone Number Attorney E-mail Phone Number B. NOTICE This serves notice that Attorney: Name Telephone Number Firm Name Fax Number Address E-mail Address City State Zip Code GA Bar Number is counsel in this case for the following named party / parties: C. CERTIFICATE OF SERVICE  I certify that I have today sent a copy of this form to all parties named above and to the State Board of Wo rkers’ Compensation, 270 Peachtree Street N.W., Atlanta, GA 30303- 1299 Signature E-mail Address Date