Georgia
State Board of Workers' Compensation Forms
on Disc v.2007
| Form # |
Revision Date |
Color |
Pages |
Title |
| SUBPOENA |
2005 |
White |
2 |
Subpoena (only
available on CD-ROM) |
| COA |
2007 |
White |
1 |
Change
of Address (only
available on CD-ROM) |
| WC-P1 |
2006 |
Pink |
1 |
Panel of Physicians |
| WC-P1SP |
2006 |
Pink |
1 |
Panel of Physicians - Spanish |
| WC-P2 |
2006 |
Pink |
1 |
Conformed Panel of Physicians |
| WC-P2SP |
2006 |
Pink |
1 |
Conformed Panel of Physicians - Spanish |
| WC-P3 |
2006 |
Pink |
1 |
WC/MCO Panel |
| WC-P3SP |
2006 |
Pink |
1 |
WC/MCO Panel - Spanish |
| WC-1 |
2007 |
White |
1 |
Employer's First Report of Injury |
| WC-2 |
2007 |
White |
2 |
Notice of Payment or Suspension
of Benefits |
| WC-2a |
2007 |
White |
2 |
Notice of Payment or Suspension
of Death Benefits |
| WC-3 |
2007 |
White |
2 |
Notice to Controvert |
| WC-4 |
2007 |
White |
1 |
Case Progress Report |
| WC-6 |
2007 |
White |
1 |
Wage Statement |
| WC-7 |
|
|
|
Application for Self-Insurance*
(Packet available through Licensure & Quality Assurance
Division (404) 656-4893) |
| WC-10 |
2006 |
White |
1 |
Notice of Election or
Rejection of Workers' Compensation Coverage |
| WC-11 |
2006 |
White |
2 |
Standard Coverage Form
Group Self-Insurance Fund Members |
| WC-12 |
2007 |
White |
1 |
Request for Copy of Board Records |
| WC-14 |
2007 |
White |
1 |
Notice of Claim/Request
for Hearing/Request for Mediation |
| WC-14a |
2007 |
White |
1 |
Request to Amend Information
on a Form WC-14 |
| WC-15 |
2007 |
White |
1 |
Attorney Certification for No Liability
Stipulations |
| WC-20(a) |
2007 |
White |
1 |
Medical Report |
| WC-24 |
2007 |
White |
1 |
Fraud And Compliance Request For
Hearing or Trial Division Intervention |
| WC-25 |
2007 |
White |
2 |
Application for Lump Sum/Advance
Payment |
| WC-26 |
2007 |
White |
1 |
Consolidated Yearly Report of Medical
Only Cases |
| WC-100 |
2007 |
White |
1 |
Settlement Mediation
Request |
| WC-102 |
2007 |
White |
1 |
Request for Documents
to Parties |
| WC-102b |
2007 |
White |
1 |
Notice of Representation |
| WC-102c |
2007 |
White |
1 |
Attorney Leave of Absence |
| WC-102d |
2007 |
White |
1 |
Motion/Objection to Motion |
| WC-104 |
2007 |
White |
1 |
Notice to Employee of
Medical Release to Return to Work with Restrictions or Limitations |
| WC-108a |
2007 |
White |
1 |
Attorney Fee Approval |
| WC-108b |
2007 |
White |
1 |
Attorney Withdrawal/Lien |
| WC-121 |
2006 |
White |
1 |
Notice of Use of Servicing Agent |
| WC-131 |
2006 |
White |
1 |
Permit
to Write Insurance |
| WC-131a |
2006 |
White |
1 |
Permit
to Write Insurance Update |
| WC-200a |
2007 |
White |
1 |
Change of Physician/Additional Treatment
by Consent |
| WC-200b |
2007 |
White |
1 |
Request/Objection for
Change of Physician/Additional Treatment |
| WC-205 |
2007 |
White |
2 |
Request for authorization of treatment or testing
b y authorized medical provider |
| WC-206 |
2007 |
White |
1 |
Notice of Intent to Become a Party
at Interest |
| WC-207 |
2007 |
White |
1 |
Authorization and Consent to Release
Information |
| WC-208a |
|
|
|
Application for Certification
of WC/MCO* (Packet available through Managed Care & Catastrophic
Disability Division (404) 656-3784) |
| WC-226a |
2007 |
White |
4 |
Petition for Appointment of Temporary Guardianship
of Minor |
| WC-226b |
2007 |
White |
4 |
Petition for Appointment of Temporary Guardianship
of Legally Incapacitated Adult |
| WC-240 |
2007 |
White |
1 |
Notice to Employee of Offer of Suitable
Employment |
| WC-240a |
2007 |
White |
2 |
Job Analysis |
| WC-243 |
2007 |
White |
1 |
Credit/Reduction in Benefits |
| WC-244 |
2007 |
White |
1 |
Notice of Intent to Become a Party
of Interest |
| WC-262 |
2007 |
White |
1 |
Wage Documentation of Temporary
Partial Disability Payments |
| WC-R1 |
2007 |
White |
2 |
Request for Rehabilitation |
| WC-R1CATEE |
|
|
|
Request for Catastrophic Designation |
| WC-R2 |
2007 |
White |
2 |
Rehabilitation Transmittal Form |
| WC-R2a |
2007 |
White |
4 |
Individualized Rehabilitation Plan |
| WC-R3 |
2007 |
White |
2 |
Request for Rehabilitation Closure |
| WC-R5 |
2007 |
White |
1 |
Request for Rehab Conference |
WC-Rehabilitation
Registration Application |
2007 |
White |
5 |
Rehabilitation
Registration Application |
WC-Rehabilitation
Registration Renewal |
2007 |
White |
3 |
Rehabilitation
Registration Renewal |
| WC-Catastrophic Rehab Release |
2007 |
White |
1 |
Rehabilitation
Registration Renewal |
| WC-BOR |
2007 |
Pink |
1 |
Bill of Rights (only on
CD-ROM) |
| WC-BOR-SP |
2007 |
Pink |
1 |
Bill of Rights - Spanish (only
on CD-ROM) |
