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Wage Documentation Form. This is a Georgia form and can be use in Workers Comp.
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Tags: Wage Documentation, WC-262, Georgia Workers Comp,
WC-262
WAGE DOCUMENTATION
GEORGIA STATE BOARD OF WORKERS' COMPENSATION
WAGE DOCUMENTATION OF TEMPORARY PARTIAL DISABILITY PAYMENTS
Instructions: Com plete this form w hen the m axim um tem porary partial disability benefits are not being paid and file w ith the Board.
When paying w eekly tem porary partial disability incom e benefit s, based upon an actual return to w ork file a Form WC-262 w ith the Board
at 13 w eek intervals or w hen such benefits are suspended, w hichever com es first. When filing the Form WC -262 w ith the Board, send a
copy to the em ployee and the
f represented.
Board Claim No.
Employ ee Last Name
Employ ee First Name
M.I.
SSN or Board Tracking #
Date of Injury
A. IDENTIFYING INFORMATION
County of Injury
Name
EMPLOYEE
EMPLOYER
Address
Phone Number
City
State
Address
City
Zip Code
Employee E-mail
Phone Number
State
Zip Code
Employer E-mail
INSURER/
SELF-INSURER
Name
SBWC ID# (five digit no.)
CLAIMS
OFFICE
Name
Address
Claims Office E-mail
Phone Number
City
State
Zip Code
B. TEMPORARY PARTIAL DISABILITY BENEFITS
START DATE
END DATE
AVERAGE
TOTAL GROSS
WEEKLY WAGE
EARNINGS
PAYMENT
2
DIFFERENCE
(W eekly W age Gross Earnings)
Difference x /3 Not to exceed
maximum stated in !34-9-262
1
2
3
4
5
6
7
8
9
10
11
12
13
TOTALS
C. CERTIFICATION
I hereby certify that to the best of my know ledge the total payments listed are correct as the available information indicates.
Print Name
E-mail
IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE B
Date
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.
WC-262
REVISION . 07/2011
262
34-9-18 AND
34-9-19).
WAGE DOCUMENTATION
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