Request For Copy Of Board Records
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Request For Copy Of Board Records Form. This is a Georgia form and can be use in Workers Comp.
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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
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