WC-14 NOTICE OF CLAIM GEORGIA STATE BOARD OF WORKERS' COMPENSATION Check only one: NOTICE OF CLAIM ONLY REQUEST HEARING / NOTICE OF CLAIM REQUEST FOR MEDIATION / NOTICE OF CLAIM Complete a new Form WC-14 to add an additional employer, insurer or to add date of injury. If you need additional space, do not alter this form, but instead attach additional sheets. Must be typed or printed in black ink. Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. CLAIM INFORMATION Birthdate County of Injury Address EMPLOYEE Employee E-mail City Name State INSURER/ SELF- INSURER EMPLOYER Name Zip Code SBWC# (five digit #) Name Address CLAIMS OFFICE Claims Address City State City Zip Code Employer E-mail State Zip Code Claims E-mail ATTORNEY FOR EMPLOYEE/CLAIMANT Name ATTORNEY FOR EMPLOYER/INSURER Address GA Bar Number City State Name Address Zip Code GA Bar Number City Attorney E-mail State Zip Code Attorney E-mail 1. Part of Body Injured 3. If Fatal Enter complete date of death Claimants for death benefits (list names & addresses) attach additional sheets 2. First Date Disabled B. HEARING / MEDIATION ISSUES Income Benefits Medical Benefits TTD(Dates) List Benefits TPD(Dates) Suspension / Termination Request PPD(Dates) Late-Payment Penalties / Assessed Attorney Fees §34-9-221e §34-9-108b (1) Catastrophic Designation §34-9-108b(2) Reason Other Specify Appeal of Rehabilitation Decision Other Effective Date Specify Specify Additional Board Claim Numbers which will be involved (if any): (Complete a separate form WC14 for each date of accident) C. AFFIRMATION OF EMPLOYEE I, [the person whose name appears above], attest and affirm that all information contained herein is true and correct to the best of my knowledge. I understand that knowingly giving false information to obtain or deny D. ENTRY OF APPEARANCE I hereby certify to the existence of a valid fee contract in compliance with Board Rule 108 or a Form WC-102B in compliance with Board Rule 102. (fee contract or WC-102B has been previously filed or is attached) E. CERTIFICATE OF SERVICE I hereby certify that I have today sent a copy of this form to all of the parties named above, and have sent this form to the State Board of Workers' Compensation, 270 Peachtree St., NW, Atlanta, Georgia 30303-1299. Print Name Phone Number Signature Date E-mail -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-14 REVISION . 07/2011 14 NOTICE OF CLAIM For injuries occurring on or after July 1, 2007, any claim filed with the Board for which neither medical nor income benefits have been paid shall stand dismissed with prejudice by operation of law if no hearing has been held within five years of the alleged date of injury. (O.C.G.A. §34-9-100) American LegalNet, Inc. www.FormsWorkFlow.com