(This notice must be posted in a conspicuous place readily accessible to the employee at all times.) OFFICIAL NOTICE CONFORMED PANEL This business operates under the Georgia Workers' Compensation Law. WORKERS MUST REPORT ALL ACCIDENTS IMMEDIATELY TO THE EMPLOYER BY ADVISING THE EMPLOYER PERSONALLY, AN AGENT, REPRESENTATIVE, BOSS, SUPERVISOR, OR FOREMAN. If a worker is injured at work, the employer shall pay medical and rehabilitation expenses within the limits of the law. In some cases the employer will also pay a part of the worker's lost wages. Work injuries and occupational diseases should be reported in writing whenever possible. The worker may lose the right to receive compensation if an accident is not reported within 30 days (see O.C.G.A. ! 34-9-80). The employer will supply free of charge, upon request, a form for reporting accidents and will also furnish, free of charge, information about workers' compensation. The employer will also furnish to the employee, upon request, copies of board forms on file with the employer pertaining to an employee's claim. A worker injured on the job must select a doctor from the list below. The minimum conformed panel shall consist of at least 10 physicians, including an orthopedic surgeon, a general surgeon, and a chiropractor, with no more than two physicians from industrial clinics (see O.C.G.A. ! 34-9-201). Further, this panel shall include one minority physician, whenever feasible (see Rule 201 for definition of minority physician). One change of doctor from the list may be made without permission. Further changes require the permission of the employer or the State Board of Workers' Compensation. State Board of Workers' Compensation 270 Peachtree Street, N.W. Atlanta, Georgia 30303-1299 404-656-3818 or 1-800-533-0682 http://www.sbwc.georgia.gov name/address/phone name/address/phone name/address/phone name/address/phone name/address/phone name/address/phone name/address/phone name/address/phone name/address/phone name/address/phone (Additional doctors may be added on a separate sheet) The insurance company providing coverage for this business under the Workers' Compensation Law is: name address phone 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-P2 (7/2006) American LegalNet, Inc. www.USCourtForms.com