WC-131a ANNUAL INSURER UPDATE GEORGIA STATE BOARD OF WORKERS' COMPENSATION ANNUAL INSURER UPDATE In conformity with Title 34, Section 34-9-131 of the Code of Georgia, it is hereby represented that the undersigned applicant has heretofore been licensed by the Insurance Commissioner of Georgia to write workers' compensation insurance, and has complied with the provisions of the laws of the State of Georgia regulating insurance companies, under the provisions of the Georgia Workers' Compensation Act. Send this form, accompanied by current GA Certificate of Authority, to the State Board of Workers' Compensation, 270 Peachtree Street NW, Atlanta, GA 30303-1299. SECTION A. CORPORATE / ADMINISTRATIVE OFFICE Name of Carrier (As it appears on permit) SBWC ID # FEIN # Address City State Zip Code Contact Person Title Toll Free Phone Number and Ext Primary E-mail Address Secondary E-mail Address SECTION B. TPA/SERVICING AGENT The above-named insurer / self-insurer / group fund has obtained the services of the following individual, firm, or company, as its servicing agent for the administration of workers' compensation claims Name of TPA / Servicing Agent FEIN # Address City State Zip Code Contact Person Title Toll Free Telephone Number and Ext Primary E-mail Address for Claims Handling Secondary E-mail Address for Claims Handling SECTION C. GEORGIA AGENT (If Section A and B are both locations outside the State of Georgia, Section C must be completed) GEORGIA AGENT MUST be located in Georgia and MUST be able to execute payment/have check writing authority. Company Contact Person Telephone Number and Ext Mailing Address City State Zip Code E-mail Address Toll Free Telephone Number and Ext The undersigned applicant covenants and agrees with the State Board of Workers' Compensation to be bound in all respects by the Georgia Workers' Compensation Act as embodied in title 34 of the Code of Georgia of 1982, as amended. Signed This Day of , 20___. Type or Print Name Signature Phone Number and Ext E-mail Address 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-131a REVISION 7/2014 131a ANNUAL INSURER UPDATE American LegalNet, Inc. www.FormsWorkFlow.com WC-131a ANNUAL INSURER UPDATE GEORGIA STATE BOARD OF WORKERS' COMPENSATION This form is due by June 1st of each year by an insurer who is currently writing workers' compensation insurance in the State of Georgia or who has requested to remain in a dormant status with the State Board of Workers' Compensation. It must be accompanied by a current Certificate of Authority from the Georgia Office of Insurance and Safety Fire Commissioner to confirm your active license status. SECTION A COPRPORATE/ADMINISTRATIVE OFFICE (all fields are mandatory in section A) 1. Name of Insurer ­ (no acronyms) SBWC ID number- (NOT the NAIC number) see our website www.sbwc.georgia.gov to verify your 2. Number 3. FEIN number 4. Mailing address, city, state, and zip code ­ this is the address that will be used by the Board for all notifications/legal notices and may be given to the public 5. Contact Person ­ this is the person the Board will contact if needed 6. Title of Contact Person 7. Toll free phone number and ext ­ this number will be used by the Board and given to the public 8. Primary e-mail address ­ this will be used by the Board for all notifications/legal notices and may be given to the public 9. Secondary e-mail address ­ this e-mail will only receive filing notifications SECTION B CLAIMS OFFICE/SERVICING AGENT Claims Office/Servicing Agent must be licensed or exempt in the State of Georgia 1. Name of Claims Office/Servicing Agent 2. FEIN # of the Claims Office/Servicing Agent 3. Mailing address, city, state, and zip code ­ this is the address that will be used by the Board for all notifications/legal notices and may be given to the public 4. Contact Person ­ this is the person the Board will contact if needed 5. Title of Contact Person 6. Toll free telephone number and ext ­ this number will be used by the Board and given to the public 7. Primary e-mail address ­ this will be used by the Board for all notifications/legal notices and may be given to the public 8. Secondary e-mail address ­ this e-mail will only receive filing notifications SECTION C GEORGIA AGENT This section is required when both locations named in sections A and B are out of state 1. 2. 3. 4. 5. 6. Company Contact Person Telephone number and ext Mailing address, city, state and zip code E-mail address Toll free telephone and ext 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-131a REVISION 7/2014 131a ANNUAL INSURER UPDATE American LegalNet, Inc. www.FormsWorkFlow.com