Get Georgia Workers' Compensation Exemption Form

The Georgia Workers' Compensation Exemption Form allows users to report injuries or occupational diseases in compliance with state regulations. This guide provides clear, step-by-step instructions on how to accurately fill out the form online, ensuring you meet all necessary requirements.

Follow the steps to complete the form accurately and efficiently.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by filling out the identifying information section. Enter the employee's last name, first name, middle initial, social security number or board tracking number, and date of injury. Do not forget to include the birthdate, gender, phone number, email, and address of the employee.
3. Next, provide details about the employer. Enter the name, physical address, and contact information, along with the National Industry Classification System (NAICS) code and nature of the business.
4. In the claims office section, provide the employer's Federal Employer Identification Number (FEIN) and email. Include the insurer or self-insurer's details, such as name and identifier numbers, along with contact information.
5. Fill out the employment and wage details. Indicate the date hired, job classification code, wage rate at the time of injury, and the normal work schedule, including normally scheduled days off.
6. In the injury/illness section, document the specifics of the incident. State the time and location of the injury, type of injury or illness, body part affected, and the treatment details. Include the name and address of the treating physician if applicable.
7. Complete the benefits section, specifying types and amounts of benefits expected, including weekly wages and compensation already paid, if applicable.
8. Sign and date the report in the section indicated for preparer information, ensuring all details are correct and thoroughly reviewed.
9. Once all information is filled out, save your changes, and download or print the form as needed for submission.

Complete your Georgia Workers' Compensation Exemption Form online to ensure prompt processing of your report.