WC-12 REQUEST FOR COPY OF BOARD RECORDS GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST FOR COPY OF BOARD RECORDS A minimum charge of $10.00 will be incurred for 10 copies or less, with a charge of $0.50 for each additional copy. All coverage information is certified with a $10.00 charge for certification. Board Claim No. Employee Last Name Employee First Name M.I. A. TYPE OF COPIES SSN or Board Tracking # Date of Injury B. REQUEST COVERAGE INFORMATION Employer Name Current Case Priors Doing Business At: Certified Copy Address Subsequent City State Zip Code C. CERTIFICATION I hereby certify that I have this day sent Compensation, 270 Peachtree Street, NW, Atlanta, GA 30303-1299, this / Day of (Day) Name (Month) (Year) Law Firm or Company Party Attorney for (Please Name) Signature Phone and Ext. E-mail GA Bar Number ADDRESS LABEL FOR BOARD USE ONLY In this space type the address to which you want these copies mailed. Do not write in this space Invoice Date Invoice Number Number of Pages Copied By: Additional Board Claim Numbers Additional Dates of Injury -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-12 REVISION . 07/2011 12 REQUEST FOR COPY OF BOARD RECORDS American LegalNet, Inc. www.FormsWorkFlow.com