Get Wc-121 - State Board Of Workers' Compensation - Georgia.gov - Sbwc Georgia

The WC-121 form is essential for notifying the State Board of Workers' Compensation in Georgia about changes related to Third Party Administrators (TPA) or servicing agents. This guide will provide you with comprehensive and clear instructions to ensure you complete the form accurately.

Follow the steps to successfully complete the WC-121 form online.

1. Click the ‘Get Form’ button to access the WC-121 form and open it in the designated editor.
2. In Section A, you must complete all mandatory fields: enter the FEIN number for the insurer, self-insurer, or group fund, along with the SBWC ID number, name of the entity (avoiding acronyms), mailing address, city, state, zip code, name of the person completing the form, name of the company, signature, date, phone number and extension, and email address.
3. If you are terminating a TPA or servicing agent, proceed to Section B. Fill in the name of the claims office being terminated, its FEIN number, and the mailing address, city, state, and zip code of that office.
4. For replacing a TPA or servicing agent, go to Section C. Complete the name of the new TPA or servicing agent, their FEIN number, and the full mailing address. Include the contact name, title, telephone number (ensure it is a local or toll-free number), fax number, email address, secondary email if applicable, and the effective date of the change.
5. If adding an additional claims office, move on to Section D. Fill in the name of the new claims office, its FEIN number, and its mailing address, city, state, and zip code. Also provide the contact name, title, telephone number, fax number, email address, secondary email if applicable, and the effective date of the change.
6. Review the completed form thoroughly to ensure all information is accurate and all necessary sections are filled out.
7. Once satisfied with the form's content, save your changes. You can then download, print, or share the completed WC-121 form as needed.

Complete your WC-121 form online today to ensure smooth processing of your change notifications.