WC-244 NOTICE OF INTENT TO BECOME A PARTY AT INTEREST GEORGIA STATE BOARD OF WORKERS' COMPENSATION NOTICE OF INTENT TO BECOME A PARTY AT INTEREST PURSUANT TO O.C.G.A 34-9-244 Instructions: Any group insurance company or other disability benefits provider who has made payments in the employee’s behalf for disability benefits pursuant to an employer paid plan, and who wishes to be named a party of 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. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION County of Injury Address EMPLOYEE Employee E-mail City Zip Code City State Zip Code Claims E-mail Name State SBWC ID# (five digit no) INSURER/ SELF INSURER EMPLOYER Address Name Name CLAIMS OFFICE Address City State Zip Code Employer E-mail B. NOTICE Notice is hereby given that: (Print Name of Group Insurance Company or Disability Benefits Provider) Address Phone City State Zip Code E-mail has made payments in the amount of $ on the employee's behalf for disability benefits and desires to be made a party at interest in this claim 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 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-244 REVISION . 07/2012 244 NOTICE OF INTENT TO BECOME A PARTY AT INTEREST American LegalNet, Inc. www.FormsWorkFlow.com