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Standard Coverage Form - Group Self Insurance Fund Members Form. This is a Georgia form and can be use in Workers Comp.
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WC-11 STANDARD COVERAGE FORM
GEORGIA STATE BOARD OF WORKERS' COMPENSATION
STANDARD COVERAGE FORM
GROUP SELF-INSURANCE FUND MEMBERS PLEASE TYPE
DETAILED INSTRUCTIONS GIVEN ON BACK OF FORM
A. INFORMATION ABOUT THE FUND MEMBER
FILE SEPARATELY FOR EACH UPDATE
1. Insured Member
5. dba (Doing Business As, if applicable)
2. Member Address
6. New dba or New Location Address
3. Type of Business
7. Franchise/Store # (if applicable)
4. EFFECTIVE DATE (Original Effective Date of Fund Member)
8. Policy Number
B. CHANGES TO ORIGINAL POLICY / ACTION REQUIRED
New dba Name
Effective Date
New Location Address
Effective Date
Member Name Listed in Section A
Effective Date
dba Name Listed in Section A
Effective Date
Location Listed in Section A
Effective Date
Name(s) in Section A
Effective Date
1. ADD
2. ADD
3. CANCEL
4. CANCEL
5. CANCEL
6. REINSTATE
NAME CHANGE (New Name Should Appear in Section A)
Member Name
Effective Date
Old dba Name
Effective Date
7.
8.
ADDRESS CHANGE (New Address Should Appear in Section A)
Member Address
9.
Old dba Address or Location Address
10.
C. INFORMATION ABOUT THE GROUP FUND AND SERVICING AGENT
Group Self-insurance Fund Name
SBWC ID# (five digit no.)
1.
Name and Address of Servicing Agent
2.
Name (of Person Completing Form)
Phone and Ext.
3.
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-11
REVISION . 07/2012
11
1 OF 2
STANDARD COVERAGE FORM
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WC-11 STANDARD COVERAGE FORM
GEORGIA STATE BOARD OF WORKERS' COMPENSATION
Use form WC-11 to:
To notify Board of coverage of new fund member, complete Sections A and C.
To notify Board of changes/activity, (as listed in Section B) complete A, B, and C.
Mail to:
Coverage Section
State Board of Workers' Compensation
270 Peachtree Street, NW
Atlanta, GA 30303-1299
404-656-3692
INSTRUCTIONS FOR COMPLETING FORM WC-11
SECTION A:
1.
ENTER COMPLETE MEMBER NAME (IF NAME HAS CHANGED, PUT NEW NAME HERE).
2.
ENTER ADDRESS OF MEMBER OFFICE (IF ADDRESS HAS CHANGED, PUT NEW ADDRESS HERE).
3.
ENTER TYPE OF BUSINESS (I.E. general contractor, retail sales, restaurant, landscaping, etc.).
4.
ENTER ORIGINAL EFFECTIVE DATE OF INSURED MEMBER.
5.
ENTER DOING BUSINESS AS (dba) NAME WHEN DIFFERENT FROM MEMBER NAME.
COMPLETE SEPARATE FORM WC-11 FOR EACH DIFFERENT (dba) NAME.
6.
ENTER ADDRESS OF (dba) LOCATION (IF MORE THAN ONE LOCATION, USE SEPARATE FORM WC-11).
7.
ENTER HERE IF A FRANCHISE OR "CHAIN" USES A STORE NUMBER TO IDENTIFY A SPECIFIC LOCATION.
8.
ENTER POLICY NUMBER ISSUED WHEN INSURANCE IS PURCHASED.
SECTION B: CHECK EXACT ACTION(s) BEING TAKEN AND GIVE EFFECTIVE DATE OF ACTION.
1.
ADD DOING BUSINESS AS (dba) NAME AS SHOWN IN SECTION A - (5).
2.
ADD LOCATION ADDRESS AS SHOWN IN SECTION A - (6).
3.
CANCEL MEMBER NAME AS IN SECTION A - (1).
4.
CANCEL DOING BUSINESS AS (dba) NAME AS SHOWN IN SECTION A - (5).
5.
CANCEL LOCATION ADDRESS AS SHOWN IN SECTION A - (6).
6.
EFFECTIVE DATE OF REINSTATEMENT.
7.
MEMBER NAME PRIOR TO NAME CHANGE.
8.
DOING BUSINESS AS (dba) NAME PRIOR TO NAME CHANGE.
9.
OLD MEMBER ADDRESS PRIOR TO ADDRESS CHANGE.
10.
OLD DOING BUSINESS AS (dba) ADDRESS PRIOR TO ADDRESS CHANGE.
1.
COMPLETE GROUP SELF-INSURANCE FUND NAME - DO NOT USE ABBREVIATIONS OR INITIALS.
2.
NAME AND ADDRESS OF THIRD PARTY ADMINISTRATOR PROCESSING CLAIMS.
3.
NAME AND PHONE NUMBER (WITH EXTENSION) OF PERSON COMPLETING FORM - DO NOT
SECTION C:
USE INITIALS.
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-11
REVISION . 07/2012
11
2 OF 2
STANDARD COVERAGE FORM
American LegalNet, Inc.
www.FormsWorkFlow.com
