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Get GA WC-3 2011-2024

A. IDENTIFYING INFORMATION Phone Number Address EMPLOYEE Employee E-mail Address City State Name Zip Code Phone Number EMPLOYER Address City State Zip Code Employer E-mail Address INSURER/ SELF-INSURER CLAIMS OFFICE Name Insurer/Self-Insurer File # Name Phone Number Address SBWC ID# (five digit no.) City State Zip Code Claims Office E-mail Address B. 1. This serves as notice, pursuant to O.C.G.A. 34-9-221, that the right to compensation in this claim is being controvert.

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