Get Ga Wc-14 2018-2026

The GA WC-14 form is essential for individuals seeking to submit a notice of claim pertaining to workers' compensation in Georgia. This guide will provide you with clear and concise instructions on how to complete the form accurately and efficiently, ensuring that your submission is complete.

Follow the steps to fill out the GA WC-14 form online

1. Click the ‘Get Form’ button to access the GA WC-14 form and open it in your preferred editor.
2. Indicate the type of claim by checking one of the provided boxes: 'Notice of claim only', 'Request hearing/notice of claim', or 'Request for mediation/notice of claim'.
3. Fill in the board claim number, if applicable.
4. For the employee section, provide the employee's last name, first name, middle initial, birthdate, and mailing address, including city, state, and zip code.
5. In the insurer/self-insurer section, enter the name and mailing address of the insurer, including city, state, and zip code, along with the five-digit SBWC number.
6. Complete the employer section with the employer's name, mailing address, email, and related information.
7. In the claim information section, enter the date of injury, county of injury, and employee email.
8. Detail the nature of the injury by specifying the part of the body affected, the first date disabled, and, if applicable, the complete date of death for fatal cases. Collect additional claimants' names and addresses on separate sheets if necessary.
9. Describe the accident in detail in the designated area.
10. Indicate the benefits being claimed by checking the relevant boxes, such as income benefits, dependency benefits, or penalties.
11. If there are hearing or mediation issues, list the benefits and any reasons for suspension or termination requests in the appropriate section.
12. In the affirmation of filing party section, ensure that the person whose name appears attests to the truth of the information provided.
13. Complete the entry of appearance by certifying the existence of a valid fee contract or attaching the required form.
14. Fill out the certificate of service section by certifying that you have sent a copy of the form to all parties and to the State Board of Workers' Compensation.
15. Finally, print your name, phone number, e-mail, and provide your signature along with the date to complete the form.
16. Once all information is filled out correctly, you can save your changes, download, print, or share the GA WC-14 form accordingly.

Start completing your GA WC-14 form online today to ensure your claim is filed correctly.