WC-121 CHANGE OF TPA / SERVICING AGENT GEORGIA STATE BOARD OF WORKERS' COMPENSATION NOTICE OF CHANGE OF TPA / SERVICING AGENT The purpose of this form is to notify the Board of a change in the TPA/Servicing Agent. This form must be completed by the Insurer, Self-Insurer or Group Fund no later than 30 days prior to the effective date of t Peachtree Street NW, Atlanta, GA 30303-1299. A TPA / Servicing Agent MUST be licensed by the Office of the Commissioner of Insurance pursuant to O.C.G.A. 33-23-100. A. INSURER/SELF-INSURER/GROUP FUND FEIN # SBWC ID # Name of Insurer / Self-Insurer / Group Fund Mailing Address City Person Completing this Form Date State Name of Company Zip Code Signature of Person Completing this Form Phone Number and Ext E-mail address B. NOTICE OF TERMINATION TPA / Servicing Agent being Terminated FEIN # Mailing Address City State Zip Code C. NOTICE OF REPLACEMENT New TPA / Servicing Agent FEIN # Mailing Address City Contact Name Title State Telephone Number (toll-free if out-of-State of Georgia) E-mail Address Zip Code Fax Number Secondary E-mail Effective Date of Change D. NOTICE OF ADDITION The above-named Insurer / Self-Insurer / Group Fund has OBTAINED the services of the following individual, firm, or company, as an additional Servicing A . Name of Servicing Agent FEIN # Mailing Address City Contact Name Title E-mail Address State Telephone Number (toll-free if out-of-State of Georgia) Secondary E-mail IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF W Zip Code Fax Number Effective Date of Change AT 404-651-7839 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-121 REVISION . 07/2011 121 CHANGE OF TPA / SERVICING AGENT American LegalNet, Inc. www.FormsWorkFlow.com