Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Notice Of Intent To Become A Party At Interest Form. This is a Georgia form and can be use in Workers Comp.
Loading PDF...
Tags: Notice Of Intent To Become A Party At Interest, WC-206, Georgia Workers Comp,
WC-206
NOTICE OF INTENT TO BECOME A PARTY AT INTEREST
GEORGIA STATE BOARD OF WORKERS' COMPENSATION
NOTICE OF INTENT TO BECOME A PARTY AT INTEREST
Instructions:
Pursuant to O.C.G.A 34-9-206, any group insurance company or other health care provider who has made payments on the
employee's behalf or provided medical services and who wishes to be named a party at interest to obtain reimbursement for those expenses which
have been paid, shall file this form, including supporting documentation, with the State Board of Workers' Compensation, 270 Peachtree Street,
N.W., Atlanta, Georgia 30303-1299.
Board Claim No.
Employee Last Name
Employee First Name
M.I.
Date of Injury
SSN or Board Tracking #
A. IDENTIFYING INFORMATION
County of Injury
Address
EMPLOYEE
Employee E-mail
City
Name
INSURER/
SELF-INSURER
EMPLOYER
Address
State
Zip Code
State
Zip Code
Name
Name
CLAIMS OFFICE
Address
City
State
Zip Code
City
Employer E-mail
Claims E-mail
B. NOTICE
Notice is hereby given that:
(Print Name Group Insurance Company or Healthcare Provider)
Address
Phone
City
State
Zip Code
E-mail
has made payments or provided medical services in the amount of $
on the employee's behalf for medical treatment, and desires to be
made a party at interest in this claim in order to demonstrate that the employer/workers' compensation carrier are responsible for reimbursement for funds so
expended, should liability be established under Title 34-9.
C. CERTIFICATION
I hereby certify that I have sent a copy of this form to all parties and counsel in this claim, and to the State Board of Workers’ Compensation, 270
Peachtree Street, N.W., Atlanta, Georgia 30303-1299
Print Name Here
Phone
Signature
E-mail
Date
GA Bar number
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.
WC-206
REVISION . 07/2011
206
34-9-18 AND
34-9-19).
NOTICE OF INTENT
TO BECOME A PARTY AT INTEREST
American LegalNet, Inc.
www.FormsWorkFlow.com
