(This notice must be posted in a conspicuous place readily accessible to the employee at all times.) OFFICIAL NOTICE This business operates under the Georgia Workers' Compensation Law. WORKERS MUST REPORT ALL ACCIDENTS IMMEDIATELY TO THE EMPLOYER BY ADVISING THE EMPLOYER PERSONALLY, AN AGENT, REPRESENTATIVE, BOSS, SUPERVISOR, OR FOREMAN. If a worker is injured at work, the employer shall pay medical and rehabilitation expenses within the limits of the law. In some cases the employer will also pay a part of the worker's lost wages. Work injuries and occupational diseases should be reported in writing whenever possible. The worker may lose the right to receive compensation if an accident is not reported within 30 days (see O.C.G.A. !34-9-80). The employer will supply free of charge, upon request, a form for reporting accidents and will also furnish, free of charge, information about workers' compensation. The employer will also furnish to the employee, upon request, copies of board forms on file with the employer pertaining to an employee's claim. State Board of Workers' Compensation 270 Peachtree Street, N.W. Atlanta, Georgia 30303-1299 404-656-3818 or 1-800-533-0682 http://www.sbwc.georgia.gov Your employer has enrolled with the certified Workers' Compensation Managed Care Organization (WC/MCO) listed below to provide all the necessary medical treatment for workers' compensation injuries. The effective date is shown below. If you had an injury prior to the effective date listed below you may continue to receive treatment from your current non-participating authorized physician until you elect to utilize the services of the WC/MCO. Each employee will be furnished with a publication which explains in detail how to access the services of the WC/MCO and provides a complete list of the medical providers available. In addition, each employee will be given a wallet-sized card which contains information on the services of the WC/MCO including a 24-hour toll-free phone number with recorded messages of information on how to utilize these services. NAME OF WC/MCO ____________________________________________________________ MAILING ADDRESS ____________________________________________________________ GEOGRAPHICAL SERVICE AREA ________________________________________________ NAME OF CONTACT PERSON ___________________________________________________ PHONE NUMBER OF CONTACT PERSON _________________________________________ ADDRESS OF CONTACT PERSON _______________________________________________ 24-HOUR TOLL-FREE PHONE NUMBER ___________________________________________ EFFECTIVE DATE OF WC/MCO __________________________________________________ The insurance company providing coverage for this business under the Workers' Compensation Law is: Name address phone 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-P3 (7/2006) American LegalNet, Inc. www.USCourtForms.com