WC-102 REQUEST FOR DOCUMENTS TO PARTIES GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST FOR DOCUMENTS TO PARTIES Instructions: NEITHER THE RESPONSE NOR REQUEST SHOULD BE FILED WITH THE BOARD. Prior to a request for hearing being filed in a claim, the parties shall be entitled to receive from each other the documents specified in this form. These documents shall be provided without cost as requested within 30 days of the date of the certificate of service. FAILURE OF THE PARTIES TO PROMPTLY EXCHANGE THESE DOCUMENTS MAY RESULT IN THE ASSESSMENT OF PENALTIES AND ATTORNEY’S FEES [SEE BOARD RULE 102(F)(1)]. Board Claim No. Employee Last Name Employee First Name M.I. Date of Injury SSN or Board Tracking # A. IDENTIFYING INFORMATION County of Injury Address City State Zip Code EMPLOYEE Name Name INSURER / SELF-INSURER EMPLOYER Address Name CLAIMS OFFICE City State Zip Code Address City ATTORNEY FOR EMPLOYEE Name State State Zip Code Name ATTORNEY FOR EMPLOYER Address Zip Code Address City State City Zip Code B. PRODUCTION OF DOCUMENTS 1. The employee hereby requests production of the following documents in the possession of the employer / insurer: Form WC-1 Form WC-2 Form WC-2a Form WC-3 Form WC-4 Form WC-6 Form WC-20a Form WC -R1, 2 and all rehabilitation supplier reports Form WC-104 Form WC-200a Form WC-200b Form WC-205 Form WC-240 with supporting documents Form WC-243 Reports prepared pursuant to Rule 200.1.(f) Medical records pursuant to Board Rule 200 (f) (2) Actual wage records of employee: Form WC- P1, 2 or 3 utilized by the employer on the date of accident Employee, from / Similarly situated employee, from / / to / / / / to / Copy of job description / analysis submitted to authorized treating physician 2. The employer / insurer hereby requests production of the following document in the possession of the employee / claimant: Wage records applicable to calculation of TPD benefits (from / / to / / ) Medical records pursuant to Board Rule 200 (f) (1) C. CERTIFICATION I hereby certify that I have this day sent a copy of this document to the above-named parties. Print Name Signature Date 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-102 REVISION . 07/2011 102 REQUEST FOR DOCUMENTS TO PARTIES American LegalNet, Inc. www.FormsWorkFlow.com