TITLE 34 LABOR AND INDUSTRIAL RELATIONS

Section 15. Reserved [Repealed].

ARTICLE 2 VENDING FACILITIES ON STATE PROPERTY

61. Publication of Notice of Operation Under the Act; Forms.

All employers operating under the Georgia Workers' Compensation Law shall post notice as hereinafter provided upon durable material publicly and permanently in a conspicuous place in each business location. [Pursuant to direction of the State Board of Workers' Compensation, the following website address has been provided:www.sbwc.georgia.gov.] Upon request, the Board will furnish suitable notices free of charge. The notice shall be in such form that it can be understood by all employees and read as follows:

The Board furnishes, upon request, copies of forms required by law. Use originals of the forms or approved copies of the original forms.The text and format of a Board form may not be altered, except with the specific written permission of the Executive Director. Generally, when filing any Board form or document with the Board, file only the original and no copies.Do not use tabs to separate documents.

Form WC-1. Employer's First Report of Injury. Employers shall complete Section A immediately upon knowledge of an injury and submit the form to their insurer. The insurer, self-insurer, or group self-insurer shall place their SBWC ID Number in the appropriate box on this form.Insurers who receive a Form WC-1 from an employer shall clearly stamp the date of receipt on the form. Insurers and self-insurers shall complete Section B or C and mail the original to the Board and a copy to the employee within 21 days of the employer's knowledge of disability. Use this form to report accidents and injuries for cases involving more than seven days of lost time. Cases with seven or less days of lost time should be reported on Form WC-26. For previously designated "medical only" claims, you must check the appropriate box in Section B or C.In death cases with accident dates before July 1, 1995, a copy of Form WC-1 shall also be filed with the Administrator of the Subsequent Injury Trust Fund at the same time it is mailed to the Board. In accepted catastrophic claims, Form WC-1 shall be filed within 48 hours of the employer's acceptance of a catastrophic injury as compensable.

Form WC-2. Notice of Payment or Suspension of Benefits. File Form WC-2 to commence, suspend, or amend the weekly benefit payment under O.C.G.A. §34-9-261, O.C.G.A. §34-9-262, or O.C.G.A. §34-9-263, including payment of salary for compensability, or when a change in disability status occurs after Form WC-1 has been properly filed with the Board. File when suspending O.C.G.A. §34-9-261 benefits and commencing O.C.G.A. §34-9-262 benefits pursuant to §34-9-104(a)(2). Serve a copy of the Form WC-2 and attachments, if any, on the employee and the employee's attorney, if one has been retained. See, Rule 221. If the last payment is intended to close the case, file final Form WC-4 with the Board.

(35) Form WC-226(b). Petition for Appointment of Temporary Conservatorship of Legally Incapacitated Adult. A party petitioning for the Board to appoint a temporary conservator to receive and administer workers' compensation benefits for a legally incapacitated adult may file this form with the WC-14 or when submitting a settlement agreement and shall serve a copy on all counsel and unrepresented parties.

Form WC-240. Notice to Employee of Offer of Suitable Employment. The employer/insurer shall use this form to notify an employee of an offer of employment which is suitable to his/her impaired condition as required by O.C.G.A. §34-9-240, and shall provide it to the employee and his/her attorney at least 10 days prior to the date the employee is scheduled to return to work. File this form as an attachment to a Form WC-2 when unilaterally suspending income benefits under Board Rule 240.

Form WC-240A. Job Analysis. An employer/insurer may use this form in conjunction with a Form WC-240 to provide a detailed job description when notifying an employee of an offer of employment which is suitable to his/her impaired condition as required by O.C.G.A. §34-9-240, and shall provide it to the employee and his/her attorney at least 10 days prior to the date the employee is scheduled to return to work. Attach this form with a Form WC-240, and file it with the Form WC-240 as an attachment to a Form WC-2 when unilaterally suspending income benefits under Board Rule 240.

Form WC-243. Credit. An employer/insurer seeking a credit pursuant to O.C.G.A. §34-9-243 shall file this with the Board and send a copy to all counsel and unrepresented parties. The employer/insurer must specify the amount of unemployment compensation and/or income payments made to the employee pursuant to a disability plan, a wage continuation plan, or a disability insurance policy, and shall specify the ratio of the employer's contributions to the total contributions of such plan or policy.

Form WC-244. Reimbursement Request of Group Insurance Carrier/Disability Benefits Provider. A group insurance carrier or disability benefits provider which requests reimbursement of disability benefits shall file this form during the pendency of a claim, and serve a copy on all counsel and unrepresented parties.

Form WC-262. Payment of Temporary Partial Disability Income Benefits. Upon payment of any temporary partial disability income benefits under O.C.G.A. §34-9-262 to an employee based on an actual return to work, an employer shall file this form with the Board and send a copy to the employee and counsel, if represented.

Form WC-Change of Address. Change of Address. This form is to be used only to change certain addresses of record.For employees, this form only changes the employee's address in a specifically identified claim.For employers and attorneys, this form only needs to be filed once as this form will change information permanently in every claim.Do not file this form if a party's address is correct, but improperly listed in a claim.

Form WC-Request to Change Information. File this form to correct the employee's name, SSN or Board Tracking Number, correct the county of injury and to correct a claims office that has been listed incorrectly in the claim. (This form can be filed by any party.)

Form WC-R1. Request for Rehabilitation. The employer/insurer shall file:

The revision effective July 1, 2007, rewrote subparagraph (b)(5)(F); added present paragraph (b)(50), and redesignated former paragraphs (b)(50) through (b)(55) as paragraphs (b)(51) through (b)(56), respectively.

The revision effective July 1, 2008, deleted "(Color of paper: Pink)" from paragraphs (b)(51) through (b)(54), and added paragraphs (b)(57) through (b)(59).

The revision effective July 1, 2009, in subsection (b), added the last three sentences in the introductory paragraph, in paragraph (b)(9), added the second sentence, in paragraph (b)(16), substituted "March 1st" for "January 31", added paragraph (b)(55), redesignated former paragraphs (b)(55) through (b)(59) as present paragraphs (b)(56) through (b)(60), respectively, and added paragraph (61).

The revision effective July 1, 2010, in subparagaraph (b)(5)(A), substituted "one year" for "180 days"; added the last sentence in paragraph (b)(10); substituted "and/or UB04" for "HCFA 1450, and/or UB92" in the introductory language of paragraph (b)(13); inserted "based on an actual return to work" in paragraph (b)(40); and, in paragraph (b)(61), deleted ", only with the prior express permission of the Board" at the end of the second sentence, and added the third sentence.

The revision effective July 1, 2014, substituted "1500 Claim Form" for "HCFA 1500" in paragraph (b)(13); substituted "Conservatorship" for "Guardianship" and substituted "conservator" for "guardian" in paragraphs (b)(34) and (b)(35); added paragraph (b)(51); and redesignated former paragraphs (b)(51) through (b)(61) as present paragraphs (b)(52) through (b)(62), respectively.

The revision effective February 16, 2016, added paragraph (b)(42); and redesignated former paragraphs (b)(42) through (b)(62) as present paragraphs (b)(43) through (b)(63), respectively.

The revision effective July 1, 2016, in paragraph (b)(2), substituted "Serve a copy of the Form WC-2 and attachments, if any, on the employee and the employee's attorney" for "Mail a copy of the Form WC-2 and attachments, if any, to the employee and their attorney"; in paragraph (b)(10), deleted "(A request for hearing by an employee will be considered only after the time required of the employer/insurer to make the first payment of income benefits has expired as provided in O.C.G.A. § 34-9-221.)" following "to all other parties" and added "Specific body parts injured must be listed on the WC-14." at the end.

The revision effective July 1, 2017, deleted "Copies of all filings shall be served on the employee and the employee's attorney, if represented." at the end of the first paragraph of subsection (b); added the undesignated paragraph following the first paragraph of subsection (b); rewrote paragraph (b)(11), which formerly read: "A party or attorney shall file this form with the Board when requesting correction of a mistake concerning the employee's name, social security number, date of injury, or county of injury on a previously filed Form WC-14. A Form WC-14A shall not be used to change an address of record, add additional parties, or additional dates of injury. A new Form WC-14 shall be filed with the Board to add or amend any information pertaining to the employer, the insurer, the servicing agent or part of body injured, and to add an additional date of injury, hearing issue, or mediation issue."; and rewrote paragraph (b)(42), which formerly read: "This form is to be used to correct an employee's name, Social Security Number or Board Tracking Number, county of injury or claims office that has been listed incorrectly in a claim."

The revision effective July 16, 2018, in the second undesignated paragraph of subsection (b), deleted "When filing via Electronic Data Interchange (EDI), and whenever an attachment to a filing or submission is required, the employer, insurer, self-insurer, group self-insurer, or designated claims office (TPAs) shall simultaneously mail to, or electronically file with, the Board the filed Subsequent Report of Injury (SROI) or Form and a copy of such attachment.", and added the first and second sentences; in the third undesignated paragraph of subsection (b), deleted "OR UNITED STATES MAIL" following "BY ELECTRONIC MAIL" in the first sentence and added the second sentence; deleted former paragraph (b)(54), which read: " Form WC-P2. Conformed Panel of Physicians. See Board Rule 201."; and redesignated former paragraphs (b)(55) through (b)(63) as present paragraphs (b)(54) through (b)(62), respectively.