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Get GA WC-14a 2018-2024

EE Employee Last Name Birthdate Employee First Name County of Injury Mailing Address City Name INSURER/ SELF-INSURER Mailing Address CLAIMS OFFICE SBWC ID # City State Date of Injury A. CLAIM INFORMATION Employee E-mail EMPLOYER M.I. Zip Code State Name Name Mailing Address City Employer E-mail Zip Code State Zip Code Claims E-mail ATTORNEY FOR EMPLOYEE/CLAIMANT Name Mailing Address GA Bar Number City State Zip Code ATTORNEY FOR EMPLOYER/INSURER Name Mailing.

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