WC-4 CASE PROGRESS REPORT GEORGIA STATE BOARD OF WORKERS' COMPENSATION CASE PROGRESS REPORT (File per Board Rule 61(b)5) Initial Board Claim No. Supplement Employee Last Name Final Reopened Employee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION Name SBWC ID# (five digit no.) Insurer /Self Insurer File Number Date of Final Weekly Payment EMPLOYER B. PAYMENT TYPE RATE Enter actual amounts paid WEEKS DAYS TOTAL PAYMENTS (a) Temporary Total (b) Temporary Partial (c) Permanent Partial (d) Death (e) Stipulation/Settlement (f) Advances C. PAYMENTS 1 Total Weekly Benefits 2 TOTAL LOST TIME PAYMENTS TO DATE Physician Benefits 3 Hospital Benefits 4 Pharmacy Benefits 5 Physical Therapy 6 Chiropractic 7 Other (Medical) 8 Rehabilitation / Vocational (excluding all of the above) 9 Late Payment Penalties 10 Assessed Attorney's Fees 11 Burial Totals D. Recovery code: for Subrogation for Overpayment for SITF Other Remarks E. I certify that the total payments are as correct as the available information indicates. Type or Print Name Signature Date Address City E-mail State Zip Code Insurer/Self Insurer Name Phone Number and Ext Claims Office Name -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-4 REVISION . 07/2011 4 CASE PROGRESS REPORT American LegalNet, Inc. www.FormsWorkFlow.com