Free Georgia Employers First Report Of Injury Of Occupational Disease PDF Download

Available for Download in PDF Format

Georgia Employers First Report Of Injury Of Occupational Disease PDF Preview

Microsoft Word - WC-001.doc

EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE

NOTE: FAILURE TO SUBMIT THIS REPORT TO INSURER IMMEDIATELY MAY RESULT IN PENALTY. MUST BE TYPED OR PRINTED IN BLACK INK.

Board Claim No.	Employee Last Name	Employee First Name	M.I.	Social Security Number	Date	of Injury

A. IDENTIFYING INFORMATION
EMPLOYEE	0 Male 0 Female	Birthdate	Phone Number	Employee E-mail
Address			City		State	Zip Code
EMPLOYER	Name		NAICS Code	Nature of Business (Trade, Transport, Mfg.,etc.)
Address			Phone Number		Employer FEIN
City		State	Zip Code	Employer E-mail
INSURER / SELF-INSURER	Name		Insurer/Self-Insurer FEIN		Insurer/ Self-Insurer File #
CLAIMS OFFICE	Name		Claims Office FEIN #	Claims Office Phone	Claims Office E-mail
SBWC ID# (five digit no.)		Address	City		State	Zip Code
EMPLOYMENT/WAGE		Date Hired by Employer	Job Classified Code No.	Number of Days Worked Per Week	Wage rate at time of Injury or Disease:	0 0	per Hour per Day
						0	per Week
Insurer Type Code 0 I – Insurer 0 S-Self-insurer 0 G-Guarantee Fund		List Normally Scheduled Days Off				0	per Month
INJURY/ILLNESS & MEDICAL	Time of Injury 0 am 0 pm	County of Injury	Date Employer had knowledge of Initial Disability		Enter First Date Employee Failed to Work a Full Day
Did Employee Receive Full Pay on Date of Injury? 0 Yes 0 No		Did Injury/Illness Occur on Employer’s premises? 0 Yes 0 No	Type of Injury/Illness	Body Part Affected
How Injury or Illness / Abnormal Health Condition Occurred
Treating Physician (Name and Address)		Initial Treatment Given:	Hospital / Treating Facility (Name and Address)		If Returned to Work, Give Date:
		0 None
		0 Minor: By Employer			Returned at what wage		per Week
		0 Minor: Clinical/Hospital
		0 Emergency Room			If Fatal, Enter Complete
		0 Hospitalized > 24hrs			Date of Death

Report Prepared By (Print or Type)			Telephone Number		Date of Report

B. INCOME BENEFITS Form WC-6 must be filed if weekly benefit is less than maximum
Previously Medical Only 0 Yes 0 No	Average Weekly Wage: $ Weekly benefit: $				Date of disability:
Date of first Payment: Compensation paid: $ or Date salary paid: Penalty paid: $ BENEFITS ARE PAYABLE FROM FOR: 0 Temporary total disability 0 Temporary partial disability 0 Permanent partial disability of % to for weeks. UNTIL WHEN THE EMPLOYEE ACTUALLY RETURNED TO WORK WITHOUT RESTRICTIONS. ALL OTHER SUSPENSIONS REQUIRE THE FILING OF FORM WC-2 WITH THE STATE BOARD OF WORKERS’ COMPENSATION AND THE EMPLOYEE.

C. NOTICE TO CONTROVERT PAYMENT OF COMPENSATION
Benefits will not be paid because:

D. MEDICAL ONLY INJURY 0 No disability paid or controverted

(Insurer / Self-Insurer: Type or Print Name of Person Filling Form)			Signature		Date
Phone and Ext.		E-mail

NOTICE TO EMPLOYER

Provide prompt medical attention; allow the employee to select a physician from your posted panel, and explain the panel to the employee.
Complete Section A of this form immediately upon your knowledge of an injury and send the WC-1 to your insurance company or self-insurer claims office. FAILURE TO DO SO MAY RESULT IN A PENALTY.
Do not send this form to the State Board of Workers' Compensation.
If you need additional help, call your insurance company or self-insurer claims office.
Report serious injuries immediately by telephone to your insurer's claims department, then file this form with your insurance company or self-insurer claims office.

NOTICE TO INSURER / SELF-INSURER

1. Complete Section B, C, or D.

This form must be filed with the State Board of Workers’ Compensation. A copy of both sides of this form must be sent to the claimant(s) and all counsel of record. Form W-6 must be filed if weekly benefits are less than the maximum.

NOTICE TO EMPLOYEE

1. This form is provided for your information only.

If Section B is completed, you will receive income benefits on a weekly basis and the employer will pay medical expenses from approved doctors. If you do not receive payment of benefits, or medical bills are not paid, call your employer or your employer's insurance company or self-insurer claims office.

If Section C is completed, your claim of injury has been denied by the employer/insurer. If you disagree with this denial, you must file a form WC-14, Notice of Claim, within one year of the accident with the State Board of Workers' Compensation, 270 Peachtree Street N.W., Atlanta, Georgia 30303-1299.

For Information or Assistance, contact:

STATE BOARD OF WORKERS' COMPENSATION

Toll Free Telephone: 1-800-533-0682 In Atlanta: (404) 656-3818

http://www.sbwc.georgia.gov

Georgia Employers First Report Of Injury Of Occupational Disease PDF Thumbnail Preview

Click to Expand

Text Preview:

WC-1 EMPLOYER�S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE GEORGIA STATE BOARD OF WORKERS' COMPENSATION EMPLOYER�S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE NOTE: FAILURE TO SUBMIT THIS REPORT TO INSURER IMMEDIATELY MAY RESULT IN PENALTY. MUST BE TYPED OR PRINTED IN BLACK INK. 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). EMPLOYER�S FIRST REPORT OF INJURY WC-1 REVISION . 07/2007 1 OR OCCUPATIONAL DISEASE 1 OF 2 WC-1 EMPLOYER�S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE GEORGIA STATE BOARD OF WORKERS' COMPENSATION NOTICE TO EMPLOYER 1. Provide prompt medical attention; allow the employee to select a physician from your posted panel, and explain the panel to the employee. 2. Complete Section A of this form immediately upon your knowledge of an injury and send the WC-1 to your insurance company or self-insurer claims office. FAILURE TO DO SO MAY RESULT IN A PENALTY. Do not send this form to the State Board of Workers' Compensation. 3. If you need additional help, call your insurance company or self-insurer claims office. 4. Report serious injuries immediately by telephone to your insurer's claims department, then file this form with yourinsurance company or self-insurer claims office. NOTICE TO INSURER / SELF-INSURER 1. Complete Section B, C, or D. This form must be filed with the State Board of Workers� Compensation. A copy of both sides of this form must be sent to the claimant(s) and all counsel of record. Form W-6 must be filed if weekly benefits are less than the maximum. NOTICE TO EMPLOYEE 1. This form is provided for your information only. If Section B is completed, you will receive income benefits on a weekly basis and the employer will pay medical expensesfrom approved doctors. If you do not receive payment of benefits, or medical bills are not paid, call your employer or youremployer's insurance company or self-insurer claims office. If Section C is completed, your claim of injury has been denied by the employer/insurer. If you disagree with this denial, you must file a form WC-14, Notice of Claim, within one year of the accident with the State Board of Workers' Compensation, 270 Peachtree Street N.W., Atlanta, Georgia 30303-1299. For Information or Assistance, contact: STATE BOARD OF WORKERS' COMPENSATION Toll Free Telephone: 1-800-533-0682 In Atlanta: (404) 656-3818 http://www.sbwc.georgia.gov 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). EMPLOYER�S FIRST REPORT OF INJURY WC-1 REVISION . 07/2007 1 OR OCCUPATIONAL DISEASE 2 OF 2

Free Auto Mechanic Resume Download

Free California Advance Health Care Directive Form 3 Download

Free Event Ticket Template 2 Download