Request For Rehab Conference
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Request For Rehab Conference Form. This is a Georgia form and can be use in Workers Comp.
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Tags: Request For Rehab Conference, WC-R5, Georgia Workers Comp,
WC-R5
REQUEST FOR REHAB CONFERENCE
GEORGIA STATE BOARD OF WORKERS' COMPENSATION
REQUEST FOR REHAB CONFERENCE
Submitted by:
Board Claim No.
Employer / Insurer
Claimant
Employ ee Last Name
Employ ee First Name
Supplier
M.I.
SSN or Board Tracking #
Date of Injury
A. IDENTIFYING INFORMATION
Phone Number
County of Injury
Name
EMPLOYEE
EMPLOYER
Address
Address
City
State
Zip Code
City
Employee E-mail
REHAB
SUPPLIER
State
Zip Code
Employer E-mail
Name
Name
INSURER /
SELF-INSURER
Address
Phone Number
CLAIMS OFFICE
Registration Number
City
State
Zip Code
Name
Address
City
Supplier E-mail
Phone Number
State
Claims E-mail
ATTORNEY FOR
EMPLOYEE / CLAIMANT
Name
Address
City
Phone Number
State
SBWC ID# (five digit no)
ATTORNEY FOR
EMPLOYER / INSURER
Phone Number
Name
Address
Zip Code
City
GA Bar number
Phone Number
State
Zip Code
GA Bar number
Attorney E-mail
Zip Code
Attorney E-mail
B. ISSUES:
C. CERTIFICATE OF SERVICE
I certify that I have today sent a copy of this form to all parties name
Street N.W., Atlanta, GA 30303-1299
Print Name Here
Telephone Number
Signature
Date
-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 SUBJE CT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A.
WC-R5
REVISION . 07/2011
R5
34-9-18 AND
34-9-19).
REQUEST FOR REHAB CONFERENCE
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