WC-REHAB OBJECTION GEORGIA STATE BOARD OF WORKERS' COMPENSATION REHAB OBJECTION Instructions: Use this form to object to Forms WC-R1, WC-R1CATEE, WC-R2A, or WC-R3. This form must be filed 20 days from the date of the certificate of service. 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 State Zip Code Name EMPLOYER Address INSURER/ SELF-INSURER CLAIMS OFFICE State Zip Code Address Name Name City Employer E-mail City State Zip Code Claims Office E-mail ATTORNEY FOR EMPLOYEE /CLAIMANT Address Name ATTORNEY FOR EMPLOYER/INSURER Address Name City State Zip Code City State Zip Code GA Bar Number GA Bar Number Attorney E-mail Attorney E-mail B. OBJECTION TO: 0 1. WC-R1 0 3. WC-R2 0 5. WC-R3 *** An argument must be attached in support of your position *** Submitted By: 0 Claimant 0 Employer/Insurer (Check One) 0 2. WC-R1CATEE 0 4. WC-R2a C. CERTIFICATE OF SERVICE 0 I hereby certify that I have today sent a copy of this form to all of the parties named above and to any/all involved rehabilitation suppliers, and have sent this form to the State Board of Workers' Compensation, 270 Peachtree Street, NW, Atlanta, Georgia 30303-1299 Print Name Signature Date Phone Number and Ext 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-REHAB OBJECTION REVISION 02/2016 REHAB OBJECTION 1 OF 1 REHAB OBJECTION American LegalNet, Inc. www.FormsWorkFlow.com