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How to fill out the WC 100 Form online
The WC 100 Form, also known as the Settlement Mediation Request, is a crucial document for initiating settlement mediation in workers' compensation claims. This guide will provide you with clear, step-by-step instructions on how to complete this form online to ensure you accurately and efficiently submit your request.
Follow the steps to successfully complete the WC 100 Form online.
- Click the ‘Get Form’ button to access the WC 100 Form and open it in your preferred online editor.
- Fill in the identifying information section. This includes the Board Claim Number, employee’s last and first names, middle initial, and social security number or Board tracking number. Be sure to provide the date of injury accurately.
- In the A. Identifying Information section, enter your name and phone number, along with the employer’s details including name, address, phone number, and county of injury. Complete both employee and employer email fields as well.
- Provide the insurer or self-insurer information in the corresponding section, including their name and contact details.
- Fill out the attorney for employer/insurer and attorney for employee/claimant sections. Include their names, addresses, phone numbers, and GA Bar Numbers where applicable.
- In section B, provide information on the settlement request. Indicate whether a Medicare Set-Aside (MSA) is involved, the designation of catastrophic injury, and if the Subsequent Injury Trust Fund (SITF) claim has been accepted.
- In the certification section (C), acknowledge that all parties agree to participate in mediation and certify good faith evaluation of the claim.
- Complete the entry of appearance (D) to certify a valid fee contract compliance.
- Fill out the certificate of service (E) by certifying that copies of the form have been sent to all parties involved and to the State Board of Workers' Compensation, including signing and dating the relevant fields.
- Once all fields are completed, review your entries for accuracy. You can then choose to save your changes, download, print, or share the completed form as needed.
Complete the WC 100 Form online today to facilitate your settlement mediation process.
Filling out a reimbursement form requires providing details on the expenses you wish to be reimbursed for, along with receipts. Make sure to categorize the expenses properly and double-check for accuracy. Using the Wc 100 Form can facilitate this process, providing a clear framework for your reimbursement requests.
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