Georgia - First Report of Injury

OPTIONAL

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A. IDENTIFYING INFORMATION

1. Board Claim No.

2. Employee Last Name

3. Employee First Name

4. Middle Initial

5. Date of Injury

Employee

6. Gender

Male Female

7. Birth Date

8. Telephone

9. Employee Email

10. Mailing Address

Address Line 1

Address Line 2

City

State

ZIP Code

Employer

11. Name

12. NAICS Code

13. Nature of Business (Trade, Transport, Mfg., etc.)

14. Mailing Address

Address Line 1

Address Line 2

City

State

ZIP Code

15. Telephone

16. Employer FEIN

17. Employer Email

Insurer / Self-Insurer

18. Name

19. Insurer / Self-Insurer FEIN

20. Insurer / Self-Insurer File #

Claims Office

21. Name

22. Claims Office FEIN #

23. Claims Office Telephone

24. Claims Office Email

25. SBWC ID # (five digit no.)

26. Mailing Address

Address Line 1

Address Line 2

City

State

ZIP Code

B. INCOME BENEFITS (Form WC-6 must be filed if weekly benefit is less than maximum)

54. Previously Medical Only

Yes No

55. Average Weekly Wage $

56. Weekly Benefit $

57. Date of Disability

58. Date of First Payment

59. Compensation paid $

60. Or, Date of Salary paid

61. Penalty paid $

62. BENEFITS ARE PAYABLE FROM

63a. BENEFITS ARE PAYABLE FOR

Temporary total disability Temporary partial disability Temporary partial disability of (continue on to 63b)...

63b. (if selected - Temporary partial disability of...)

Fill in blanks, but include text.

64. UNTIL ________ WHEN THE EMPLOYEE ACTUALLY RETURNED TO WORK WITHOUT RESTRICTIONS. ALL OTHER SUSPENSIONS REQUIRE THE FILING OF FORM WC-2 WITH THE STATE BOARD OF WORKERS' COMPENSATION AND THE EMPLOYEE

C. NOTICE TO CONTROVERT PAYMENT OF COMPENSATION

65. Benefits will not be paid because:

D. MEDICAL ONLY INJURY (No indemnity benefits are due and/or have NOT been controverted.)

66. Insurer / Self-Insurer: Name of Person Filing Form

67. Date

68. Phone Number

69. Email

OPTIONAL

A. IDENTIFYING INFORMATION

Employee

Employer

Insurer / Self-Insurer

Claims Office

Employment / Wage

Injury / Illness & Medical

B. INCOME BENEFITS (Form WC-6 must be filed if weekly benefit is less than maximum)

C. NOTICE TO CONTROVERT PAYMENT OF COMPENSATION

D. MEDICAL ONLY INJURY (No indemnity benefits are due and/or have NOT been controverted.)