WC-CHANGE OF ADDRESS GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST FOR CHANGE OF ADDRESS Instructions: This form is to be used only to change certain addresses of record. For employees, this form only changes the eeds to be filed once as this a claim. A. EMPLOYEE CHANGE OF ADDRESS Board Claim Number Employee Last Name Employee First Name M.I. Old Phone Number Date of Injury New Phone Number Old Address SSN or Board Tracking # New Address City State Zip Code City Old E-mail Address State Zip Code New E-mail Address B. ALL OTHER PARTY ADDRESS CHANGES EMPLOYER Name FEIN Old Phone Number New Phone Number Old Address New Address City State Zip Code City Old E-mail Address ATTORNEY State Zip Code New E-mail Address For Employ ee Other Name GA Bar number For Employ er Old Phone Number New Phone Number Old Address New Address City State Zip Code City Old E-mail Address PARTY AT INTEREST State Zip Code State Zip Code New E-mail Address Name Old Phone Number New Phone Number Old Address New Address City State Zip Code City Old E-mail Address New E-mail Address C. CERTIFICATE OF SERVICE I certify that I have today sent a copy of this form to all of the parties and have sent this form to the State Board of Work Compensation, 270 Peachtree Street, NW, Atlanta, GA 30303-1299 Print Name Here Phone Number Signature Date E-mail IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF W ORKERS 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). REVISION . 07/2011 WC-CHANGE OF ADDRESS American LegalNet, Inc. www.FormsWorkFlow.com