Get GA WC-102 2018-2024

WC-102 REQUEST FOR DOCUMENTS TO PARTIES GEORGIA STATE BOARD OF WORKERS COMPENSATION Instructions NEITHER THE RESPONSE NOR REQUEST SHOULD BE FILED WITH THE BOARD. FAILURE OF THE PARTIES TO PROMPTLY EXCHANGE THESE DOCUMENTS MAY RESULT IN THE ASSESSMENT OF PENALTIES AND ATTORNEY S FEES SEE BOARD RULE 102 F 1. Board Claim No. Employee Last Name Employee First Name M. I. A. IDENTIFYING INFORMATION County of Injury Mailing Address City Date of Injury State Zip Code EMPLOYEE Name INSURER / SELF-INSURER CLAIMS OFFICE ATTORNEY FOR B. PRODUCTION OF DOCUMENTS 1. The employee hereby requests production of the following documents in the possession of the employer / insurer Form WC-1 Form WC-20a Form WC -R1 2 and all rehabilitation supplier reports Actual wage records of employee / Employee from Similarly situated employee from Form WC-240 with supporting documents Form WC-243 Reports prepared pursuant to Rule 200. Prior to a request for hearing being filed in a claim the parties shall be entitled to receive from each other the documents specified in this form* These documents shall be provided without cost as requested within 30 days of the date of the certificate of service. FAILURE OF THE PARTIES TO PROMPTLY EXCHANGE THESE DOCUMENTS MAY RESULT IN THE ASSESSMENT OF PENALTIES AND ATTORNEY S FEES SEE BOARD RULE 102 F 1. Board Claim No* Employee Last Name Employee First Name M. I. A. IDENTIFYING INFORMATION County of Injury Mailing Address City Date of Injury State Zip Code EMPLOYEE Name INSURER / SELF-INSURER CLAIMS OFFICE ATTORNEY FOR B. PRODUCTION OF DOCUMENTS 1. The employee hereby requests production of the following documents in the possession of the employer / insurer Form WC-1 Form WC-20a Form WC -R1 2 and all rehabilitation supplier reports Actual wage records of employee / Employee from Similarly situated employee from Form WC-240 with supporting documents Form WC-243 Reports prepared pursuant to Rule 200. 1. f Medical records pursuant to Board Rule 200 f 2 Form WC- P1 2 or 3 utilized by the employer on the date of accident Employee s written or recorded statement s to Copy of job description / analysis submitted to authorized treating physician 2. The employer / insurer hereby requests production of the following document in the possession of the employee / claimant Wage records applicable to calculation of TPD benefits from C. CERTIFICATE OF SERVICE I hereby certify that I have this day sent a copy of this document to the above-named parties. Print Name Signature Date IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http //www. sbwc*georgia*gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO 10 000. Prior to a request for hearing being filed in a claim the parties shall be entitled to receive from each other the documents specified in this form* These documents shall be provided without cost as requested within 30 days of the date of the certificate of service. FAILURE OF THE PARTIES TO PROMPTLY EXCHANGE THESE DOCUMENTS MAY RESULT IN THE ASSESSMENT OF PENALTIES AND ATTORNEY S FEES SEE BOARD RULE 102 F 1. .