EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE WC-1 GEORGIA STATE BOARD OF WORKERS' COMPENSATION EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE NOTE: FAILURE TO SUBMIT THIS REPORT TO INSURER IMMEDIATELY MAY RESULT IN PENALTY. MUST BE TYPED OR PRINTED IN BLACK INK. Board Claim No. Employee Last Name Employee First Name M.I. Date of Injury SSN or Board Tracking # A. IDENTIFYING INFORMATION Birthdate Male EMPLOYEE Phone Number Employee E-mail Female Address City Name EMPLOYER State NAICS Code Address Nature of Business (Trade, Transport, Mfg., etc.) Phone Number City State Zip Code Insurer/Self-Insurer FEIN Name CLAIMS OFFICE Employer FEIN Employer E-mail Name INSURER / SELF-INSURER Claims Office FEIN # SBWC ID# (five digit no.) Address Insurer/ Self-Insurer File # Claims Office Phone Claims Office E-mail City Date Hired by Employer Zip Code Job Classified Code No. State Zip Code Wage rate at time of Injury or Disease: Number of Days Worked Per Week EMPLOYMENT/WAGE per Hour per Day per Week Insurer Type Code – Insurer List Normally Scheduled Days Off S-Self-insurer Enter First Date Employee Failed to Work a Full Day am pm Did Employee Receive Full Pay on Date of Injury? Yes Date Employer had knowledge of Injury County of Injury Time of Injury INJURY/ILLNESS & MEDICAL per Month Group Fund Did Injury/Illness Occur on Employer’s premises? No Yes Type of Injury/Illness Body Part Affected No How Injury or Illness / Abnormal Health Condition Occurred Treating Physician (Name and Address) Initial Treatment Given: None Hospital / Treating Facility (Name and Address) Minor: By Employer If Returned to Work, Give Date: Minor: Clinical/Hospital Returned at what wage Emergency Room If Fatal, Enter Complete Date of Death Hospitalized > 24hrs Report Prepared By (Print or Type) Telephone Number B. INCOME BENEFITS No Date of Report Form WC-6 must be filed if weekly benefit is less than maximum Previously Medical Only Yes per Week Date of disability: Average Weekly Wage: $ Date of first Payment: Weekly benefit: $ Compensation paid: $ BENEFITS ARE PAYABLE FROM Temporary total disability or Date salary paid: Penalty paid: $ FOR: Temporary partial disability Permanent partial disability of % to for weeks. UNTIL WHEN THE EMPLOYEE ACTUALLY RETURNED TO WORK WITHOUT RESTRICTIONS. ALL OTHER SUSPENSIONS REQUIRE THE FILING OF FORM WC-2 WITH THE STATE BOARD OF WORKERS’ COMPENSATION AND THE EMPLOYEE. C. NOTICE TO CONTROVERT PAYMENT OF COMPENSATION Benefits will not be paid because: D. MEDICAL ONLY INJURY No disability paid or controverted Insurer / Self-Insurer: Type or Print Name of Person Filing Form Signature Phone and Ext. 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-1 REVISION . 07/2011 1 1 OF 2 EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE American LegalNet, Inc. www.FormsWorkFlow.com WC-1 EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE GEORGIA STATE BOARD OF WORKERS' COMPENSATION NOTICE TO EMPLOYER 1. Provide prompt medical attention; allow the employee to select a physician from your posted panel, and explain the panel to the employee. 2. Complete Section A of this form immediately upon your knowledge of an injury and send the WC-1 to your insurance company or self-insurer claims office. FAILURE TO DO SO MAY RESULT IN A PENALTY. Do not send this form to the State Board of Workers' Compensation. 3. If you need additional help, call your insurance company or self-insurer claims office. 4. Report serious injuries immediately by telephone to your insurer's claims department, then file this form with your insurance company or self-insurer claims office. NOTICE TO INSURER / SELF-INSURER 1. Complete Section B, C, or D. This form must be filed with the State Board of Workers’ Compensation. A copy of both sides of this form must be sent to the claimant(s) and all counsel of record. Form W-6 must be filed if weekly benefits are less than the maximum. NOTICE TO EMPLOYEE 1. This form is provided for your information only. If Section B is completed, you will receive income benefits on a weekly basis and the employer will pay medical expenses from approved doctors. If you do not receive payment of benefits, or medical bills are not paid, call your employer or your employer's insurance company or self-insurer claims office. If Section C is completed, your claim of injury has been denied by the employer/insurer. If you disagree with this denial, you must file a form WC-14, Notice of Claim, within one year of the accident with the State Board of Workers' Compensation, 270 Peachtree Street N.W., Atlanta, Georgia 30303-1299. For Information or Assistance, contact: STATE BOARD OF WORKERS' COMPENSATION Toll Free Telephone: 1-800-533-0682 In Atlanta: (404) 656-3818 http://www.sbwc.georgia.gov 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-1 REVISION . 07/2011 1 2 OF 2 EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE American LegalNet, Inc. www.FormsWorkFlow.com