WC-240 NOTICE TO EMPLOYEE OF OFFER OF SUITABLE EMPLOYMENT GEORGIA STATE BOARD OF WORKERS' COMPENSATION NOTICE TO EMPLOYEE OF OFFER OF SUITABLE EMPLOYMENT Instructions: The employer shall use this form to notify an employee of an offer of employment which is suitable to his/her impaired condition, as required by O.C.G.A. 34-9-240 and Board Rule 240. This form, with all attachments, must be provided to the employee and counsel for the employee at least ten days prior to the date the employee is expected to return to work. This form, along with attachments, should only be filed with the Board as an attachment to a Form WC-2. Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION EMPLOYEE County of Injury Address Employee E-mail City Name State Zip Code State Zip Code Address EMPLOYER Employer E-mail City B. NOTICE TO EMPLOYEE This is to inform you that the following job is being made available to you pursuant to the requirements of O.C.G.A. 34-9-240 and Board Rule 240 (b): 1. Title Essential Duties (Attach Additional Pages as needed) Rate of Pay Location of Job Hours / Days to be Worked Date / Time to Report for Work 2. A copy of the report(s) of your authorized treating physician(s), approving the job as suitable to your condition, is / are attached. 3. If you unjustifiably refuse to attempt to performs the job offered after receiving this notification, the employer / insurer shall be authorized to suspend payment of income benefits to you effective the date you are scheduled to report to work. Should you attempt but fail to continue working for fifteen (15) scheduled work days, your income benefits shall immediately be reinstated. 4. If you have any questions about the job being offered to you, you may contact the employer at: . C. CERTIFICATION I hereby certify that the above-named job is available to this employee as outlined above, that the job duties have been approved by the authorized treating physician(s) who has examined the employee within 60 days of the attached approval, and that this offer is being made in good faith no later than ten days prior to the date the employee is expected to report for work. I further certify that I have this day sent a copy of this form to the employee and counsel for employer (if represented.) Print Name / Title Here E-mail Signature Address Date IF YOU HAVE QUESTIONS PLEASE CON City State Zip Code -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-240 REVISION . 07/2011 240 NOTICE TO EMPLOYEE OF OFFER OF SUITABLE EMPLOYMENT American LegalNet, Inc. www.FormsWorkFlow.com