WC-243 CREDIT GEORGIA STATE BOARD OF WORKERS' COMPENSATION CREDIT Instructions: When seeking credit/reimbursement pursuant to O.C.G.A. 34-9-243, the employer shall file this form with the State Board of Workers' Compensation, 270 Peachtree Street, N.W., Atlanta, Georgia 30303-1299, and send a copy to all counsel and unrepresented parties immediately upon seeking credit, and in any event no later than 10 days prior to a hearing. 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 Employee E-mail City Name State State INSURER/ SELF-INSURER EMPLOYER Address Zip Code Zip Code Name Name CLAIMS OFFICE Address City State Zip Code City Employer E-mail Claims E-mail SBWC ID# (five digit no) B. CREDIT REQUESTED 1. A credit is requested as allowed by O.C.G.A. 34-9-243 for benefits paid under the "Employment Security Law" or employer funded portions of payments received by the employee pursuant to: Unemployment compensation payments Wage continuation plan Disability plan Disability insurance policy 2. The employee has been paid weekly benefits of $ through 3. / / X $ (weekly disability benefit per plan or policy) / , for which credit is sought. The ratio of the employer’s contributions to the total contributions of the plan or policy is calculated as follows: / , from the date of %. The amount of credit per week will be % = $ (Ratio of contributions) (to be credited against TTD or TPD benefits due.) Credit shall not exceed the amount of income benefits due the employee. C. CERTIFICATION I hereby certify that the above information is true and correct to the best of my knowledge and a copy of this form has been sent to the Board, to counsel, and to all unrepresented parties in this claim. Print Name Here Phone Signature Date E-mail 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-243 REVISION . 07/2011 243 CREDIT American LegalNet, Inc. www.FormsWorkFlow.com