Notice Of Representation Of Any Party Other Than Claimant Or Employer By Attorney
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Notice Of Representation Of Any Party Other Than Claimant Or Employer By Attorney Form. This is a Georgia form and can be use in Workers Comp.
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Tags: Notice Of Representation Of Any Party Other Than Claimant Or Employer By Attorney, WC-102B, Georgia Workers Comp,
WC-102b
NOTICE OF REPRESENTATION OF ANY PARTY OTHER THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY
GEORGIA STATE BOARD OF WORKERS' COMPENSATION
NOTICE OF REPRESENTATION OF ANY PARTY
OTHER THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY
(This form is not to be filed by an attorney for claimant / employee)
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
ATTORNEY FOR
EMPLOYEE /
CLAIMANT
State
State
Name
Zip Code
Zip Code
Name
EMPLOYER
Address
Address
City
State
Zip Code
City
GA Bar number
Employer E-mail
Attorney E-mail
INSURER /
SELF-INSURER
Name
Name
PARTY AT
INTEREST
Name
CLAIMS OFFICE
Address
Address
City
State
Zip Code
Party E-mail
SBWC ID # (five digit no.)
City
State
Zip Code
Claims E-mail
B. NOTICE
This serves notice that Attorney:
of the firm:
at mailing address:
Telephone Number
City
Fax Number
State
E-mail Address
Zip Code
GA Bar Number
Is counsel in this case for the following named party / parties:
C. CERTIFICATION
on, 270 Peachtree
Street N.W., Atlanta, GA 30303-1299
Signature
E-mail Address
Date
-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-102b
REVISION . 07/2011
102b
NOTICE OF REPRESENTATION OF ANY PARTY OTHER
THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY
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