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The Georgia WC 102B form is an essential document used in the workers' compensation process within the state. This form serves as a formal notice of representation by an attorney for any party other than the claimant or employee, ensuring that all relevant parties are informed of legal representation in a case. It requires the identification of key information such as the employee's name, date of injury, and the county where the injury occurred. Additionally, the form collects details about the attorney representing the party, including their contact information and Georgia Bar number. Employers and insurers are also identified, which helps to clarify the parties involved in the claim. A certification section at the end of the form confirms that a copy has been sent to all parties and the State Board of Workers' Compensation. This notification process is crucial for maintaining transparency and accountability in workers' compensation claims. Understanding the WC 102B form is vital for anyone navigating the complexities of workers' compensation law in Georgia.

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WC-102b NOTICE OF REPRESENTATION OF ANY PARTY OTHER THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

NOTICE OF REPRESENTATION OF ANY PARTY

OTHER THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY

(This form is not to be filed by an attorney for claimant / employee)

Board Claim No.

Employee Last Name

Employee First Name

M.I.

SSN or Board Tracking #

Date of Injury

A. IDENTIFYING INFORMATION

County of Injury

EMPLOYEE

Employee E-mail

Address

City

State

Zip Code

ATTORNEY FOR EMPLOYEE / CLAIMANT

Name

EMPLOYER

Name

 

Address

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

Zip Code

City

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

GA Bar number

 

 

 

 

Employer E-mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attorney E-mail

 

 

 

 

INSURER /

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SELF-INSURER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PARTY AT

Name

 

 

CLAIMS OFFICE

Name

 

 

INTEREST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

Address

 

 

 

SBWC ID # (five digit no.)

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

Zip Code

City

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

Party E-mail

Claims E-mail

B. NOTICE

This serves notice that Attorney:

 

 

 

of the firm:

 

 

 

at mailing address:

 

 

 

Telephone Number

 

 

 

 

City

State

Zip Code

Fax Number

E-mail Address

 

GA Bar Number

Is counsel in this case for the following named party / parties:

C. CERTIFICATION

I certify that I have today sent a copy of this form to all parties named above and to the State Board of Workers’ Compensation, 270 Peachtree Street N.W., Atlanta, GA 30303-1299

Signature

E-mail Address

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 $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19).

WC-102b

REVISION . 07/2011 102b

NOTICE OF REPRESENTATION OF ANY PARTY OTHER

THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY
➤ PDF File

Form Specifications

Fact Name Details
Form Purpose The WC-102B form notifies the Georgia State Board of Workers' Compensation of an attorney's representation of a party other than a claimant or employee.
Governing Law This form is governed by the Georgia Workers' Compensation Act, specifically O.C.G.A. § 34-9-18 and § 34-9-19.
Filing Requirement Attorneys for claimants or employees should not file this form.
Identifying Information Key details such as the employee's name, date of injury, and county of injury must be provided.
Attorney Information The form requires the attorney's name, bar number, and contact details, including email and phone number.
Employer Details Information about the employer, including name and address, must be included in the form.
Insurer Information The form collects details about the insurer or self-insurer, including the SBWC ID number.
Certification Requirement The attorney must certify that a copy of the form has been sent to all parties involved and to the State Board.
Consequences of False Statements Providing false information on this form can lead to penalties of up to $10,000 per violation.

Georgia Wc 102B: Usage Guidelines

Completing the Georgia WC 102B form is an essential step for attorneys representing parties other than the claimant or employee in a workers' compensation case. Following these steps will help ensure that all necessary information is accurately provided.

  1. Begin by locating the Board Claim Number. This is essential for identifying the specific case.
  2. Fill in the Employee Last Name, Employee First Name, and M.I. (Middle Initial).
  3. Provide the Social Security Number or Board Tracking Number.
  4. Enter the Date of Injury and the County of Injury.
  5. Input the Employee E-mail Address, followed by the City, State, and Zip Code for the employee.
  6. In the section for the Attorney for Employee/Claimant, write the attorney's Name and GA Bar Number.
  7. Provide the Employer Name and their Address, including City, State, and Zip Code.
  8. Fill in the Insurer/Self-Insurer Name and the Claims Office Name.
  9. Complete the Address for the Claims Office, including City, State, and Zip Code.
  10. Enter the SBWC ID # (a five-digit number).
  11. Provide the Party E-mail and Claims E-mail.
  12. In the NOTICE section, fill in the Attorney's Name, Firm Name, Mailing Address, Telephone Number, City, State, Zip Code, Fax Number, E-mail Address, and GA Bar Number.
  13. Identify the party or parties for whom the attorney is counsel in this case.
  14. Finally, in the CERTIFICATION section, the attorney must sign and date the form. Ensure that a copy of the form has been sent to all parties named and to the State Board of Workers’ Compensation.

Your Questions, Answered

What is the Georgia WC 102B form?

The Georgia WC 102B form is a document used to notify the State Board of Workers' Compensation when an attorney represents a party other than the claimant or employee in a workers' compensation case. It helps ensure that all parties are informed about legal representation involved in the case.

Who needs to fill out the WC 102B form?

This form must be completed by attorneys representing parties other than the employee or claimant. It is important for attorneys to provide clear representation details to avoid any confusion regarding who is involved in the case.

What information is required on the form?

The form requires identifying information about the employee, the attorney, the employer, and the insurer or self-insurer. This includes names, addresses, email addresses, and the Georgia Bar number of the attorney. Accurate information is crucial for proper communication.

When should the WC 102B form be submitted?

The form should be submitted as soon as the attorney begins representation in the case. Prompt filing helps keep all parties informed and ensures that the case proceeds smoothly.

How is the WC 102B form submitted?

The completed form must be sent to all parties named on the form and to the State Board of Workers’ Compensation at their Atlanta address. It's essential to follow these steps to ensure proper notification.

What happens if the form is not filed?

If the WC 102B form is not filed, it may lead to confusion about representation. This could result in delays in the case or complications in communication between parties involved.

Can anyone file the WC 102B form?

No, only attorneys representing parties other than the claimant or employee can file this form. Claimants and employees should not submit this form themselves.

What are the penalties for providing false information on the form?

Providing false information on the WC 102B form is considered a crime. Penalties can reach up to $10,000 for each violation. It is critical to ensure all information is accurate and truthful.

Where can I find more information about the WC 102B form?

For additional questions, you can contact the State Board of Workers’ Compensation at 404-656-3818 or 1-800-533-0682. You can also visit their website at http://www.sbwc.georgia.gov for more resources and information.

Common mistakes

Filling out the Georgia WC 102B form correctly is crucial for ensuring proper representation in workers' compensation cases. However, many individuals make common mistakes that can lead to delays or complications. Below is a list of ten frequent errors made when completing this form.

  1. Incomplete Identifying Information:

    Failing to provide all required identifying details such as the employee's full name, Social Security Number, and date of injury can result in processing delays.

  2. Incorrect County of Injury:

    Listing the wrong county where the injury occurred can complicate jurisdictional issues and affect the case outcome.

  3. Missing Attorney Information:

    Not including the attorney's name, contact information, or Georgia Bar number can lead to confusion about representation.

  4. Employer Details Not Provided:

    Omitting the employer's name and address can hinder communication between involved parties.

  5. Failure to Notify All Parties:

    Not sending copies of the form to all parties named can violate procedural requirements and lead to disputes.

  6. Signature Issues:

    Submitting the form without a signature or with an illegible signature can invalidate the document.

  7. Incorrect Email Addresses:

    Providing incorrect email addresses for any party can prevent important communications from being received.

  8. Missing Certification:

    Failing to complete the certification section can result in the form being rejected.

  9. Not Keeping Copies:

    Neglecting to retain copies of the submitted form for personal records can create issues if questions arise later.

  10. Ignoring Deadlines:

    Submitting the form late or after the designated deadline can jeopardize the case and affect benefits.

Each of these mistakes can significantly impact the effectiveness of the representation in a workers' compensation case. Attention to detail is essential when completing the Georgia WC 102B form.

Documents used along the form

When navigating the complexities of workers' compensation in Georgia, various forms and documents play crucial roles. The Georgia WC-102B form, which serves as a notice of representation by an attorney for parties other than the claimant or employee, is just one part of the process. Understanding additional forms that accompany this document can streamline communication and ensure compliance with legal requirements. Here are some commonly used forms in conjunction with the WC-102B:

  • WC-1: Employer's First Report of Injury - This form is submitted by the employer to report a workplace injury to the State Board of Workers' Compensation. It includes details about the incident, the injured employee, and the nature of the injury.
  • WC-3: Notice of Claim - This document is filed by the injured employee or their attorney to formally initiate a claim for workers' compensation benefits. It outlines the specifics of the injury and the requested benefits.
  • WC-4: Employee's Claim for Compensation - This form allows the employee to provide detailed information about their claim for compensation. It includes medical expenses, lost wages, and other relevant details.
  • WC-6: Notice of Payment - This notice is sent by the employer or insurer to inform the employee about the benefits being paid. It includes information on the type and amount of benefits provided.
  • WC-14: Request for Hearing - If disputes arise regarding a claim, this form is used to request a formal hearing before an administrative law judge. It outlines the issues in contention and the desired resolution.
  • WC-16: Application for Approval of Settlement - This document is filed when parties reach a settlement agreement. It requests the State Board's approval of the settlement terms.
  • WC-17: Agreement as to Compensation - This form is used to outline the agreement between the employer and the employee regarding compensation benefits. It serves as a record of the agreed-upon terms.
  • WC-22: Notice of Change in Condition - If there are any changes in the employee's medical condition or ability to work, this form must be filed to update the State Board and other involved parties.
  • WC-23: Final Report of Injury - This report is submitted by the employer once the employee has reached maximum medical improvement or the claim is otherwise resolved. It summarizes the claim's outcome and any ongoing obligations.

Each of these forms plays a vital role in the workers' compensation process in Georgia. Familiarity with them not only aids in compliance but also empowers injured workers and their representatives to effectively navigate the system. Understanding the interplay between these documents can lead to a smoother claims experience and better outcomes for all parties involved.

Similar forms

The Georgia WC 102B form serves a specific purpose in the workers' compensation process, primarily to notify the State Board of Workers' Compensation and other involved parties about legal representation. Several other forms share similar functions or purposes within the realm of workers' compensation and legal representation. Here are four documents that are comparable to the Georgia WC 102B form:

  • WC-101: This form is the "Notice of Claim." It is used by employees to formally notify their employer and the State Board of Workers' Compensation that they are filing a claim for benefits. Like the WC 102B, it establishes communication among parties involved in a workers' compensation case.
  • WC-103: Known as the "Notice of Controversion," this form is filed by an employer or insurer to indicate that they are disputing a claim. Similar to the WC 102B, it serves to inform the relevant parties about the status of the claim and the representation involved.
  • WC-104: This is the "Settlement Agreement." It outlines the terms agreed upon by the parties involved in a workers' compensation claim. While the WC 102B notifies about representation, the WC 104 formalizes the resolution of the claim, ensuring all parties are aware of the agreement reached.
  • WC-105: The "Request for Hearing" form is utilized when a party seeks a formal hearing regarding a dispute in a workers' compensation case. This document, like the WC 102B, ensures that all parties are informed of the proceedings and the representation involved in the hearing.

Dos and Don'ts

When filling out the Georgia WC 102B form, attention to detail is crucial. Here are five important do's and don'ts to keep in mind.

  • Do ensure all identifying information is accurate, including names, addresses, and Social Security numbers.
  • Do provide complete contact information for all parties involved, including email addresses and phone numbers.
  • Do double-check the GA Bar number of the attorney representing the party.
  • Do sign and date the form before submission to confirm its authenticity.
  • Do send a copy of the completed form to all parties named above and to the State Board of Workers' Compensation.
  • Don't leave any sections blank; incomplete forms can lead to delays.
  • Don't use incorrect or outdated information, as this can cause legal complications.
  • Don't forget to include the party's email address; this is important for communication.
  • Don't submit the form without reviewing it for errors or omissions.
  • Don't ignore the warning about making false statements; this can have serious legal consequences.

Misconceptions

Misunderstandings about the Georgia WC 102B form can lead to confusion for those involved in workers' compensation cases. Here are seven common misconceptions:

  1. Only claimants need to use this form. Many believe that the WC 102B form is solely for claimants or employees. In reality, it serves as a notice for any party represented by an attorney, not just those filing a claim.
  2. This form is optional. Some think that completing the WC 102B form is optional. However, it is essential for ensuring all parties are informed about legal representation in a case.
  3. The form must be filed with the court. There’s a misconception that this form needs to be filed with a court. Instead, it should be sent to the State Board of Workers’ Compensation and all involved parties.
  4. Attorneys for claimants can use this form. It's commonly believed that any attorney can submit this form. However, it is specifically for attorneys representing parties other than the claimant or employee.
  5. Filing this form guarantees legal representation. Some individuals think that simply filing the form means they have legal representation. While it notifies others of representation, it does not establish an attorney-client relationship.
  6. The form can be completed without specific information. There’s a belief that the WC 102B can be filled out with minimal details. In truth, accurate and complete information is crucial for the form to be valid.
  7. Once submitted, no further action is needed. Many assume that submitting the form is the final step. However, ongoing communication and updates may be necessary as the case progresses.

Understanding these misconceptions can help clarify the role and importance of the Georgia WC 102B form in the workers' compensation process.

Key takeaways

When dealing with the Georgia WC 102B form, it is essential to understand its purpose and how to fill it out correctly. Here are some key takeaways to keep in mind:

  • Purpose of the Form: The WC 102B form is used to notify the Georgia State Board of Workers' Compensation that an attorney is representing a party other than the claimant or employee.
  • Who Should Not File: Attorneys representing claimants or employees should not file this form. It is specifically for other parties involved in the case.
  • Identifying Information: Accurate information must be provided, including the employee's name, date of injury, and the county where the injury occurred.
  • Attorney Information: The form requires detailed information about the attorney, including their name, contact information, and Georgia Bar number.
  • Certification Requirement: The attorney must certify that they have sent copies of the form to all parties involved and to the State Board of Workers’ Compensation.
  • Penalties for False Statements: It is crucial to be truthful when filling out the form. Willfully making false statements can lead to significant penalties, including fines up to $10,000.

By following these guidelines, individuals can ensure that they complete the WC 102B form correctly and avoid potential legal issues.