WC - 26 CONSOLIDATED YEARLY REPORT OF MEDICAL ONLY CASES / INDEMNITY CASES GEORGIA STATE BOARD OF WORKERS' COMPENSATION CONSOLIDATED YEARLY REPORT OF MEDICAL ONLY CASES AND ANNUAL PAYMENTS ON INDEMNITY CLAIMS st File on or before March 1 following each calendar year. A. INSURER/SELF-INSURER/GROUP FUND NOTE: INSURERS / SELF-INSURERS / GROUP FUND USE NAME AS IT APPEARS ON PERMIT Insurer/Self-Insurer/Group Fund SBWC ID# (five digit no.) Reporting Year IT IS THE RESPONSIBILITY OF THE INSURER OR SELF-INSURER TO CONSOLIDATE ALL INDIVIDUAL CLAIMS OFFICE REPORTS INTO ONE REPORT AND SUBMIT YEARLY TO THE STATE BOARD OF WORKERS' COMPENSATION. THE TOTAL NUMBER OF CLAIMS AND TOTAL MONEY REPORTED IS FOR A CALENDAR YEAR JANUARY 1st TO DECEMBER 31st. FILE ANNUALLY EVEN IF NO REPORTABLE INJURIES OR PAYMENTS OCCURRED DURING THE REPORTING YEAR. B. MEDICAL ONLY CLAIMS PLEASE REPORT TOTAL YEARLY MEDICAL EXPENSES BELOW: Total Number of Medical Only Claims this Year Total Amount Paid on Medical Only Claims this Year I certify to the best of my knowledge the total payments shown have not been reported as lost time medical on a form WC-4 C. INDEMNITY CLAIMS Total Amount of Income Benefits Paid On Indemnity Claims This Year Total Number of Indemnity Claims This Year Total Amount of Temporary Total Benefits Paid This Year Total Amount of Temporary Partial Benefits Paid This Year Total Amount of Permanent Partial Benefits Paid This Year Total Medical Paid on Indemnity Claims This Year (Do not include hospital payments) Total Hospital payments on Indemnity Claims This Year Insurer/Self Insurer/Group Fund (Type or Print Name of Person Filing Form) Signature Date Address of Insurer/Self Insurer/Group Fund (not the claims office) Phone Number and Ext E-mail Mail to: State Board of Workers’ Compensation, 270 Peachtree St, NW, Atlanta, GA 30303-1299 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-26 REVISION . 07/2012 26 CONSOLIDATED YEARLY REPORT OF MEDICAL ONLY CASES / INDEMNITY CASES American LegalNet, Inc. www.FormsWorkFlow.com