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Blank Georgia Wc 14 PDF Form

The Georgia WC-14 form is a critical document used to notify the State Board of Workers' Compensation about a claim for benefits related to workplace injuries. This form can serve multiple purposes, including filing a notice of claim, requesting a hearing, or seeking mediation. If you need to submit a claim, be sure to fill out the form accurately by clicking the button below.

Article Guide

The Georgia WC-14 form is a crucial document in the workers' compensation process, serving multiple purposes for employees, employers, and insurers. It allows individuals to formally notify the Georgia State Board of Workers' Compensation about a claim. Users can select from various options, including submitting a notice of claim only, requesting a hearing, or seeking mediation. The form requires detailed information about the employee, including their name, birthdate, and mailing address, as well as specifics about the injury, such as the date it occurred and the part of the body affected. It also includes sections for the employer's and insurer's details, ensuring that all parties are properly identified. Additionally, the WC-14 form addresses various issues related to the claim, such as temporary total disability, medical benefits, and dependency benefits. A key feature is the affirmation section, where the filer attests to the accuracy of the information provided, highlighting the seriousness of submitting false statements. Finally, the form mandates a certificate of service, confirming that all relevant parties have been notified. This comprehensive approach ensures that the claims process is transparent and accountable.

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WC-14 NOTICE OF CLAIM

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

Check only one:  NOTICE OF CLAIM ONLY REQUEST HEARING / NOTICE OF CLAIM  REQUEST FOR MEDIATION / NOTICE OF CLAIM

Complete a new Form WC-14 to add an additional employer, insurer or to add date of injury.

If you need additional space, do not alter this form, but instead attach additional sheets. Must be typed or printed in black ink.

Board Claim No.

Employee Last Name

Employee First Name

M.I.

Date of Injury

A. CLAIM INFORMATION

EMPLOYEE

Birthdate

County of Injury

Mailing Address

Employee E-mail

City

State

Zip Code

Name

INSURER/

Name

SBWC# (five digit #)

EMPLOYER

SELF- INSURER

Mailing Address

City

State

Zip Code

City

State

Zip Code

Employer E-mail

Insurer E-mail

ATTORNEY FOR

Name

ATTORNEY FOR

Name

EMPLOYEE/CLAIMANT

EMPLOYER/INSURER

Mailing Address

GA Bar Number

Mailing Address

GA Bar Number

City

State

Zip Code

City

State

Zip Code

Attorney E-mail

1. Part of Body Injured

2. First Date Disabled

3. If Fatal – Enter complete date of death

Claimants for death benefits (list names & addresses) attach additional sheets

4. Description of Accident

B. HEARING / MEDIATION ISSUES

TTD(Dates)



Medical Benefits

List Benefits:

 Income Benefits

TPD(Dates)

PPD(Dates)

 Suspension / Termination Request

Effective Date

Reason:

 Dependency Benefits



Burial Expenses

Penalties / Assessed Attorney Fees

	§34-9-221e	§34-9-108b (1)		§34-9-108b(2)		Other

	Request for Catastrophic Designation				Specify:			Appeal of Rehabilitation Decision	Specify:
	Request for Catastrophic Designation							Appeal of Rehabilitation Decision

	Other		Specify:					Additional Board Claim Numbers which will be involved (if any):
	Other
	Hearing Issues
	Hearing Issues						 (Complete a separate form WC14 for each date of accident)
							 (Complete a separate form WC14 for each date of accident)

C. AFFIRMATION OF FILING PARTY

I, [the person whose name appears above], attest and affirm that all information contained herein is true and correct to the best of my knowledge. I understand that knowingly giving false information to obtain or deny workers’ compensation benefits subjects me to civil and criminal penalties.

D. ENTRY OF APPEARANCE

I hereby certify to the existence of a valid fee contract in compliance with Board Rule 108 or a Form WC-102B in compliance with Board Rule 102. (fee contract or WC-102B has been previously filed or is attached)

E. CERTIFICATE OF SERVICE

I hereby certify that I have today sent a copy of this form to all of the parties and have sent this form to the State Board of Workers' Compensation, 270 Peachtree St., NW, Atlanta, Georgia 30303-1299.

Print Name

Signature

Date

Phone Number

E-mail

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-14

REVISION 12/2018

NOTICE OF CLAIM

For injuries occurring on or after July 1, 2007, any claim filed with the Board for which neither medical nor income benefits have been paid shall stand dismissed with prejudice by operation of law if no hearing has been held within five years of the alleged date of injury. (O.C.G.A. §34-9-100)

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Form Specifications

Fact Name	Details
Form Purpose	The WC-14 form is used to notify the Georgia State Board of Workers' Compensation of a claim.
Submission Options	Claimants can submit a notice of claim only, request a hearing, or request mediation.
Completing the Form	The form must be typed or printed in black ink. Additional sheets may be attached if more space is needed.
Claimant Information	Essential information includes the employee's name, date of injury, and mailing address.
Injury Details	Claimants must specify the part of the body injured and the first date of disability.
Filing Affirmation	Filing parties must affirm the truthfulness of the information provided, acknowledging penalties for false statements.
Attorney Certification	Attorneys must certify the existence of a valid fee contract or attach a Form WC-102B.
Certificate of Service	Claimants must certify that a copy of the form has been sent to all parties and the State Board.
Governing Laws	The form is governed by O.C.G.A. §34-9-18, §34-9-19, and §34-9-100.

Georgia Wc 14: Usage Guidelines

Completing the Georgia WC-14 form is a critical step in the workers' compensation process. After filling out this form, you will need to submit it to the State Board of Workers' Compensation and send copies to all relevant parties. Make sure to double-check your entries for accuracy, as errors can lead to delays in processing your claim.

Begin by selecting one of the three options at the top of the form: NOTICE OF CLAIM ONLY, REQUEST HEARING / NOTICE OF CLAIM, or REQUEST FOR MEDIATION / NOTICE OF CLAIM.
Fill in the Board Claim No., Employee Last Name, Employee First Name, and M.I. (Middle Initial).
Enter the Date of Injury and complete the Employee Information section, including Birthdate, County of Injury, Mailing Address, Email, City, State, and Zip Code.
Provide the Insurer/Employer Information, including the Name, Mailing Address, City, State, Zip Code, and Email. Don't forget to include the SBWC#.
Complete the Attorney Information section if applicable, providing the Name, Mailing Address, GA Bar Number, City, State, Zip Code, and Email for both the employee and employer attorneys.
In the Claim Information section, specify the Part of Body Injured, First Date Disabled, and if applicable, the Date of Death along with names and addresses of claimants for death benefits.
Describe the accident in the provided space under Description of Accident.
Check any relevant issues under the Hearing / Mediation Issues section, including TTD, Medical Benefits, Income Benefits, and others as applicable.
In the AFFIRMATION OF FILING PARTY section, attest that all information is true and correct by checking the box and signing your name.
If you are an attorney, certify the existence of a valid fee contract in the ENTRY OF APPEARANCE section.
Finally, complete the CERTIFICATE OF SERVICE section by certifying that you have sent copies of the form to all parties and to the State Board of Workers' Compensation.

Your Questions, Answered

What is the purpose of the Georgia WC-14 form?

The Georgia WC-14 form serves as a notice of claim for workers' compensation. It allows employees or their representatives to formally notify the State Board of Workers' Compensation about a claim related to a workplace injury. The form can also be used to request a hearing or mediation regarding the claim. Proper completion of this form is essential for ensuring that all relevant parties are informed and that the claim is processed efficiently.

Who should fill out the WC-14 form?

The WC-14 form should be filled out by the employee or their attorney if they are seeking to claim benefits for a work-related injury. It can also be completed by the employer or insurer if they are responding to a claim. Each party must provide accurate information regarding the injury, including details about the employee, the employer, and the nature of the claim.

What information is required on the WC-14 form?

Essential information on the WC-14 form includes the employee's name, birthdate, mailing address, and details about the injury, such as the date of injury and part of the body injured. Additionally, the form requires information about the employer and insurer, including their names and contact details. Any claims for specific benefits, such as medical or income benefits, must also be indicated on the form.

How do I submit the WC-14 form?

Once the WC-14 form is completed, it must be submitted to the State Board of Workers' Compensation. This can be done by mailing the form to the address provided on the form or by delivering it in person. It is crucial to ensure that a copy of the form is sent to all involved parties, as certification of this action is required on the form itself.

What happens if I do not file the WC-14 form within the required time frame?

If the WC-14 form is not filed within the specified time frame, the claim may be dismissed. For injuries occurring on or after July 1, 2007, if no hearing has been held within five years of the alleged date of injury, the claim will be dismissed with prejudice by operation of law. This means that the claim cannot be refiled, underscoring the importance of timely submission.

What are the consequences of providing false information on the WC-14 form?

Providing false information on the WC-14 form can lead to serious legal repercussions. Willfully making a false statement to obtain or deny workers' compensation benefits is considered a crime and can result in penalties of up to $10,000 per violation. It is vital to ensure that all information provided is accurate and truthful to avoid these severe consequences.

Common mistakes

Failing to check the correct box for the type of claim being filed. Choose only one option: Notice of Claim Only, Request Hearing / Notice of Claim, or Request for Mediation / Notice of Claim.
Not providing complete information about the employee, including the last name, first name, and middle initial. Missing details can delay processing.
Leaving out the date of injury. This is crucial for establishing the timeline of the claim.
Using incorrect ink color. The form must be typed or printed in black ink only.
Not including the complete mailing addresses for the employer, insurer, and attorney. Incomplete addresses can hinder communication.
Failing to list all necessary parties involved in the claim. This includes the names and addresses of claimants for death benefits, if applicable.
Neglecting to specify the type of benefits being claimed. Clearly indicate whether you are requesting TTD, TPD, PPD, or other benefits.
Not providing an accurate description of the accident. This section is vital for understanding the circumstances surrounding the claim.
Overlooking the affirmation section. The form must be signed and dated by the filing party to validate the claim.
Failing to send copies of the form to all relevant parties and the State Board of Workers' Compensation. Ensure compliance with the Certificate of Service.

Documents used along the form

The Georgia WC-14 form is a crucial document for initiating a workers' compensation claim. It serves as a notice of claim and can also request a hearing or mediation. When completing the WC-14, several other forms may be necessary to support your claim or address specific issues. Below is a list of commonly used forms and documents that complement the WC-14.

WC-1: Employer's First Report of Injury - This form must be completed by the employer to report an employee's injury to the State Board of Workers' Compensation. It provides essential details about the incident and the injured worker.
WC-2: Notice of Payment of Compensation - Employers use this form to notify the Board and the injured worker about the payment of benefits. It outlines the type and amount of compensation being provided.
WC-3: Notice of Termination of Benefits - When an employer intends to stop paying benefits, this form must be submitted. It explains the reasons for the termination and ensures compliance with legal requirements.
WC-102: Attorney Fee Contract - If an attorney is representing the injured worker, this form documents the agreement regarding attorney fees. It must be filed with the Board to ensure transparency.
WC-102B: Attorney Fee Agreement - Similar to the WC-102, this form specifies the fee arrangement between the attorney and the client. It is essential for maintaining compliance with Board rules.
WC-4: Request for Hearing - If there are disputes regarding the claim, this form is used to formally request a hearing before the Board. It outlines the issues that need to be resolved.
WC-5: Request for Mediation - This document is used when parties wish to resolve disputes through mediation rather than a formal hearing. It encourages a collaborative approach to settle claims.
WC-6: Application for Catastrophic Designation - If the injury is severe and qualifies for catastrophic designation, this form is necessary. It helps to secure additional benefits for the injured worker.
WC-7: Application for Rehabilitation Benefits - This form is used to request vocational rehabilitation services for injured workers who need assistance in returning to work.

Each of these forms plays a vital role in the workers' compensation process in Georgia. Properly completing and submitting the necessary documentation can significantly impact the outcome of a claim. Understanding these forms will help ensure that all parties are informed and that the process runs smoothly.

Similar forms

WC-1 Form: This form serves as the initial report of injury, similar to the WC-14 in that it documents the details of a workplace injury. Both forms require information about the employee, employer, and nature of the injury.
WC-2 Form: The WC-2 is used to report changes in the employee's work status or benefits. Like the WC-14, it requires detailed information about the employee and the circumstances surrounding the claim.
WC-3 Form: This form is for reporting wage loss due to a work-related injury. It parallels the WC-14 by focusing on the financial impact of the injury on the employee.
WC-4 Form: The WC-4 is a request for additional benefits. Similar to the WC-14, it outlines the specific benefits being sought and requires comprehensive information about the claim.
WC-6 Form: This form is used to request a hearing. It shares similarities with the WC-14 in that both documents initiate a formal process regarding a claim.
WC-7 Form: The WC-7 is for reporting a change in the employee's medical condition. Like the WC-14, it requires updates on the employee’s status and related medical details.
WC-10 Form: This form is used for reporting a claim for death benefits. It is similar to the WC-14 as it also requires detailed information about the deceased employee and the circumstances of the claim.
WC-11 Form: The WC-11 is a request for a lump-sum settlement. Like the WC-14, it involves a formal request related to the claim and requires detailed documentation.
WC-12 Form: This form is utilized to request a change in medical providers. It parallels the WC-14 by addressing the need for updates in the claim process.
WC-102B Form: This form is a fee contract for attorneys representing claimants. It is similar to the WC-14 in that it outlines the legal representation involved in the claim process.

Dos and Don'ts

Filling out the Georgia WC-14 form correctly is essential for ensuring your claim is processed smoothly. Here are five important things to do and avoid when completing this form.

Do ensure all information is accurate and complete. Double-check names, dates, and addresses.
Do use black ink or type the information. This helps maintain clarity and readability.
Do attach additional sheets if you need more space. Do not alter the original form.
Do sign and date the form before submission. This confirms your affirmation of the information provided.
Do send copies to all parties involved, including the State Board of Workers' Compensation.

Don't leave any sections blank. Incomplete forms can lead to delays in processing.
Don't provide false information. Misrepresentation can lead to serious penalties.
Don't forget to include the Board Claim Number. This is crucial for tracking your claim.
Don't use pencil or colored ink. Stick to black ink or typing for clarity.
Don't ignore the submission deadlines. Timeliness is key to ensuring your claim is considered.

Misconceptions

Misconception 1: The WC-14 form is only for new claims.

This is not true. The WC-14 form can also be used to add additional employers or insurers, or to update the date of injury. It serves multiple purposes beyond just initiating a new claim.

Misconception 2: You can alter the WC-14 form to add more information.

Altering the form is not allowed. If you need more space, you should attach additional sheets instead. This keeps the process organized and ensures all information is clearly presented.

Misconception 3: Submitting the WC-14 form is the final step in the claims process.

Submitting the form is just one step. After filing, you may need to participate in hearings or mediation sessions. The process can involve multiple stages, depending on the specifics of your case.

Misconception 4: The WC-14 form is only for workers with injuries.

While it primarily addresses injuries, the form can also be used for claims related to fatalities. In such cases, additional information about the deceased and dependents must be provided.

Misconception 5: You don’t need to notify all parties when filing the WC-14 form.

This is incorrect. You must certify that you have sent copies of the form to all involved parties, including the State Board of Workers' Compensation. This ensures transparency and keeps everyone informed.

Key takeaways

When filling out the Georgia WC-14 form, it’s essential to pay attention to the details. Here are some key takeaways to keep in mind:

Choose the Correct Option: Select only one option at the top of the form: Notice of Claim Only, Request Hearing/Notice of Claim, or Request for Mediation/Notice of Claim.
Provide Accurate Information: Ensure all fields are filled out completely, including your name, date of injury, and details about the employer and insurer.
Use the Correct Format: The form must be typed or printed in black ink. If you need more space, attach additional sheets rather than altering the form.
Be Specific About the Injury: Clearly describe the part of the body injured and provide the first date disabled. If applicable, include details about any fatal incidents.
Affirm the Information: The person filing must attest that all information is true and correct. False statements can lead to serious penalties.
Submit Properly: After completing the form, send a copy to all relevant parties and the State Board of Workers' Compensation at the specified address.

Following these guidelines can help ensure that your claim is processed efficiently and accurately.