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Motion-Objection To Motion Form. This is a Georgia form and can be use in Workers Comp.
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Tags: Motion-Objection To Motion, WC-102D, Georgia Workers Comp,
WC-102d
MOTION / OBJECTION TO MOTION
GEORGIA STATE BOARD OF WORKERS' COMPENSATION
MOTION / OBJECTION TO MOTION
Motion
Objection to Motion
When you receive this completed form, you may file a response 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
County of Injury
Address
EMPLOYEE
E-mail Address
City
Name
State
State
Address
Zip Code
State
INSURER /
SELF-INSURER
EMPLOYER
Zip Code
Zip Code
Name
Name
CLAIMS OFFICE
Address
City
State
Zip Code
City
Employer E-mail
ATTORNEY FOR
EMPLOYEE / CLAIMANT
Claims E-mail
Name
ATTORNEY FOR
EMPLOYER / INSURER
Address
City
Name
Address
State
Zip Code
City
GA Bar Number
GA Bar Number
Attorney E-mail
Attorney E-mail
B. ACTION REQUESTED
1. This MOTION is being requested by
The purpose of this motion is to request:
Employee
Employer/Insurer
Other Party
(Arguments and documentation in support of this motion are attached.)
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 attached.)
C. ENTRY OF APPEARANCE
I hereby certify to the existence of a valid fee contract in compliance with Board Rule 108 or Form WC 102B filed in compliance of Board Rule
102. (A fee contract or Form WC 102B has been filed previously or is attached).
D. CERTIFICATE OF SERVICE
I hereby certify that the parties have made a good faith 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 of this form with supporting documentation to the State Board of Workers’ Compensation and to all parties and
counsel in this claim.
Print Name Here
Phone Number
Signature
Date
E-mail Address
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 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-102d
REVISION . 07/2012
102d
MOTION / OBJECTION TO MOTION
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