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In the realm of workers' compensation in Georgia, the WC-3 form plays a crucial role in managing disputes over claims. This form, known as the "Notice to Controvert," is primarily used by employers or insurers to formally contest an employee's right to compensation following a workplace injury. It requires essential information such as the employee's details, the nature of the injury, and the specific reasons for disputing the claim. There are several grounds for controverting a claim, including questioning the compensability of medical treatments or asserting that the right to compensation is being challenged for particular reasons. Completing the WC-3 form accurately is vital; it must be filed with the Georgia State Board of Workers' Compensation within a specific timeframe to avoid penalties. Additionally, a copy of this notice must be provided to all parties involved, ensuring transparency and communication throughout the process. Understanding the nuances of the WC-3 form is essential for both employees and employers, as it can significantly impact the outcome of a claim.

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WC-3 NOTICE TO CONTROVERT

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

NOTICE TO CONTROVERT

Board Claim No.

Employee Last Name

Employee First Name

M.I.

Date of Injury

 

 

 

 

A. IDENTIFYING INFORMATION

 

 

 

 

 

EMPLOYEE

 

Mailing Address

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee E-mail Address

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER

 

Name

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

Employer E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURER/

 

Name

 

 

Insurer/Self-Insurer File #

 

 

 

 

 

 

 

 

 

SELF-INSURER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIMS

 

Name

 

 

Claims Office E-mail

 

 

 

 

 

 

 

 

 

 

 

OFFICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SBWC ID

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

B. CONTROVERT TYPES

1. This serves as notice, pursuant to O.C.G.A. §34-9-221, that the right to compensation in this claim is being controverted on the following

 

specific grounds:

 

 

 

2.

This is notice, pursuant to O.C.G.A. §34-9-200 and Board Rule 205(b), that the compensability of the following medical treatment / test is

 

 

being controverted for the following specific reasons:

 

 

 

3.

If only part of the claim is being controverted, state the specific part of the claim and the reason(s) it is being controverted:

 

 

 

 

 

C. CERTIFICATE OF SERVICE

 

 

This is to certify that a copy of both sides of this notice has been sent to the employee / claimant(s), all counsel of record and any other person with

 

a financial interest, as listed below:

 

 

 

 

 

 

 

 

 

 

 

 

 

Type or Print Name

 

Signature

 

Date

 

 

 

 

 

Phone Number

 

E-mail Address

 

 

 

 

This form must be filed with the State Board of Workers' Compensation. A copy of both sides of this form must be given to the employee and any other

person with a financial interest in the claim including, but not limited to the employer, medical care provider(s) and attorney(s).

 

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).

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NOTICE TO CONTROVERT

 

 

 

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WC-3

NOTICE TO CONTROVERT

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

INFORMATION FOR THE INSURER/SELF-INSURER:

Board Rule 61(b)(1): An insurer who receives a Form WC-1 from an employer shall clearly stamp the date of receipt on the form, review Section A, and complete any unanswered questions. The insurer shall complete either Section B or Section C or Section D and, by the 21st day following the employer's knowledge of disability, forward the original to the Board and a copy to the employee.

Board Rule 61(b)(4): previously been filed. 9-221 and Rule 221.

Form WC-3. Notice to Controvert Payment of Compensation. Complete Form WC-3 to controvert when a Form WC-1 has Furnish copies to employee and any other person with a financial interest in the claim. See subsections (d), (h), and (i) of Code §34-

O.C.G.A. §34-9-221(d): If the employer controverts the right of compensation, it shall file with the Board, on or before the twenty-first day after knowledge of the alleged injury or death, a notice in accordance with the form prescribed by the Board, stating that the right of compensation is controverted and stating the name of the claimant, the name of the employer, the date of the alleged injury or death, and the ground upon which the right to compensation is controverted.

Board Rule 221(d): To controvert in whole or in part the right to income benefits or other compensation use Form WC-1 or WC-3. Failure to file the Forms WC-1 or WC-3 before the 21st day after knowledge of the injury or death may subject the employer/insurer to assessment of attorney's fees. See O.C.G.A. §34-9-108(b)(2)(3).

O.C.G.A. §34-9-221(h): When compensation is being paid without an award, the right to compensation shall not be controverted except upon the grounds of change in condition or newly discovered evidence unless a notice to controvert is filed with the Board within 60 days of the due date of first payment of compensation.

Board Rule 221(h)(1): A Form WC-3 shall not be used to suspend benefits if the only issue is length of disability. In these cases, suspend benefits by filing a Form WC-2 or follow the procedure outlined in Rule 240. If liability is denied subsequent to commencement of payment, but within 60 days of due date of first payment of compensation, file Form WC-3 in addition.

O.C.G.A. §34-9-221(i): When compensation is being paid with or without an award and an employer or insurer elects to controvert on the grounds of a change in condition or newly discovered evidence, the employer shall, not later than 10 days prior to the due date of the first omitted payment of income benefits, file with the Board and the employee or beneficiary a notice to controvert the claim in a manner prescribed by the Board.

Board Rule 221(h)(2): If income benefits have been continued for more than 60 days after the due date of first payment of compensation, benefits may be suspended only on the grounds of a change in condition or newly discovered evidence. File Forms WC-2 or WC-2(a). When controverting a claim based on newly discovered evidence, file Form WC-3 also.

O.C.G.A. §34-9-108(b)(2): If any provision of Code Section §34-9-221, without reasonable grounds, is not complied with and a claimant engages the services of an attorney to enforce rights under that Code Section and the claimant prevails, the reasonable fee of the attorney, as determined by the Board, and the costs of the proceedings may be assessed against the employer.

INFORMATION FOR THE EMPLOYEE:

This claim is being controverted for the reason(s) indicated on the front of this form. If you disagree, you should request a hearing by sending Form WC-14 to the State Board of Workers’ Compensation at the address below. If you need a Form WC-14, please contact the State Board of Workers’ Compensation at the phone numbers listed below or visit the website.

STATE BOARD OF WORKERS' COMPENSATION

270 Peachtree Street, N.W. Atlanta, Georgia 30303-1299 In Atlanta: 404-656-3818

or: 1-800-533-0682

http://www.sbwc.georgia.gov

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).

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➤ PDF File

Form Specifications

Fact Name Details
Purpose of Form The WC-3 form serves as a Notice to Controvert, informing the State Board of Workers' Compensation that an employer or insurer is disputing a worker's compensation claim.
Governing Laws This form is governed by O.C.G.A. §34-9-221 and Board Rule 221, which outline the requirements for disputing compensation claims in Georgia.
Filing Deadline The form must be filed within 21 days of the employer's knowledge of the injury or death to avoid penalties, as specified in O.C.G.A. §34-9-221(d).
Certificate of Service Section C of the form includes a Certificate of Service, confirming that copies of the notice have been sent to all relevant parties.
Consequences of False Statements Providing false information on the form can lead to penalties of up to $10,000, as per O.C.G.A. §34-9-18 and §34-9-19.
Employee Rights If a claim is controverted, the employee has the right to request a hearing by submitting Form WC-14 to the State Board.

Georgia Wc 3: Usage Guidelines

Completing the Georgia WC-3 form is a crucial step in the process of formally disputing a workers' compensation claim. Follow these instructions carefully to ensure all necessary information is provided accurately.

  1. Begin by entering the Board Claim Number at the top of the form.
  2. Fill in the Employee's Last Name, First Name, and Middle Initial.
  3. Specify the Date of Injury.
  4. In Section A, provide the Employee's Mailing Address, including City, State, and Zip Code.
  5. Enter the Employee's E-mail Address and Phone Number.
  6. Next, complete the Employer's Name, Phone Number, and Mailing Address in the same format as the employee's information.
  7. Fill in the Employer's E-mail Address.
  8. In the Insurer/Self-Insurer section, provide the Name and File Number.
  9. Complete the Claims Office Name and its E-mail Address.
  10. Fill out the SBWC ID and the Mailing Address for the claims office.
  11. In Section B, indicate the type of controversion by checking the appropriate box. Provide specific grounds for the controversion as needed.
  12. In Section C, certify that a copy of this notice has been sent to all relevant parties by typing or printing your name, signing, and dating the form.
  13. Finally, include your Phone Number and E-mail Address in the designated area.

Once completed, submit the form to the State Board of Workers' Compensation. Ensure that copies are provided to the employee and any other parties with a financial interest in the claim. If you have questions, reach out to the State Board for assistance.

Your Questions, Answered

What is the purpose of the Georgia WC-3 form?

The Georgia WC-3 form, also known as the Notice to Controvert, serves as an official document to notify the State Board of Workers' Compensation that an employer or insurer is disputing a worker's compensation claim. This form outlines the specific grounds for the controversion, which may include disputes over the right to compensation or the compensability of medical treatment.

Who is required to file the WC-3 form?

The employer or insurer must file the WC-3 form. This requirement arises when they wish to contest a claim for workers' compensation benefits. The form must be submitted to the State Board of Workers' Compensation within 21 days after the employer becomes aware of the injury or disability.

What information is needed to complete the WC-3 form?

To complete the WC-3 form, the filer must provide identifying information about the employee, such as their name, address, and date of injury. Additionally, details about the employer and insurer must be included. The specific grounds for the controversion should also be clearly stated in the form.

What are the consequences of failing to file the WC-3 form on time?

If the WC-3 form is not filed within the required 21-day period, the employer or insurer may face penalties, including the potential assessment of attorney's fees. This can occur if a claimant engages legal representation to enforce their rights under the workers' compensation laws and prevails in their case.

Can the WC-3 form be used to suspend benefits?

The WC-3 form cannot be used to suspend benefits if the only issue in question is the length of disability. Instead, in such cases, a different form, the WC-2, should be filed. However, if the employer or insurer wishes to controvert a claim based on newly discovered evidence or a change in condition, the WC-3 form may be applicable.

What should an employee do if they disagree with the controversion?

If an employee disagrees with the reasons stated in the WC-3 form for the controversion of their claim, they have the right to request a hearing. This can be done by submitting a Form WC-14 to the State Board of Workers' Compensation. The employee may contact the Board for assistance in obtaining this form or for further guidance.

What are the penalties for making false statements on the WC-3 form?

Willfully making false statements on the WC-3 form in order to obtain or deny benefits is considered a crime. Penalties can include fines of up to $10,000 for each violation, as stipulated by Georgia law. It is crucial for all parties involved to provide accurate and truthful information when filing this form.

Common mistakes

Filling out the Georgia WC-3 form can be complex. Here are nine common mistakes to avoid:

  1. Incomplete Identifying Information:

    Ensure all sections, including employee and employer details, are fully filled out. Missing information can delay processing.

  2. Incorrect Claim Number:

    Double-check the claim number for accuracy. An incorrect number can lead to confusion and misdirection of your form.

  3. Failure to Specify Grounds for Controversion:

    Clearly state the specific grounds for controversion. Vague reasons may lead to rejection of the form.

  4. Not Including All Required Signatures:

    All necessary parties must sign the form. Missing signatures can invalidate the submission.

  5. Neglecting to Certify Service:

    It’s crucial to certify that copies were sent to all relevant parties. Failure to do so may result in penalties.

  6. Filing After Deadline:

    Submit the form within the required timeframe. Late submissions can lead to penalties or loss of rights.

  7. Using Outdated Forms:

    Always use the most current version of the WC-3 form. Outdated forms may not be accepted.

  8. Ignoring Instructions:

    Follow the instructions provided on the form carefully. Ignoring them can result in incomplete submissions.

  9. Providing Inaccurate Contact Information:

    Ensure that all contact information is accurate and up-to-date. Incorrect details can hinder communication.

By avoiding these mistakes, you can help ensure that your Georgia WC-3 form is processed smoothly and efficiently.

Documents used along the form

The Georgia WC-3 form is an essential document used in workers' compensation cases to formally dispute a claim. Along with the WC-3, there are several other forms that are commonly utilized in the process. Here’s a brief overview of five important documents that may accompany the WC-3 form.

  • WC-1: Employer's First Report of Injury - This form is submitted by the employer to report an employee's injury or illness. It provides the initial details of the incident, including the nature of the injury and circumstances surrounding it.
  • WC-14: Request for Hearing - If a party disagrees with the decision made regarding a workers' compensation claim, they can file this form to request a hearing. It initiates the process for a formal review of the case.
  • WC-2: Notice of Suspension of Benefits - This document is used by employers or insurers to notify the employee that they are suspending benefits. It must include the reasons for the suspension and comply with specific regulations.
  • WC-2(a): Notice of Change in Condition - When there is a change in the employee's medical condition affecting their benefits, this form must be filed. It serves to inform the employee of the new circumstances regarding their claim.
  • WC-4: Employee's Claim for Benefits - This form is used by employees to formally request workers' compensation benefits. It outlines the details of the claim and the benefits being sought.

Understanding these forms and their purposes can help ensure that all parties involved in a workers' compensation claim are properly informed and that the process runs smoothly. Each document plays a critical role in the overall claims process.

Similar forms

The Georgia WC-3 form, known as the Notice to Controvert, serves a specific purpose in the workers' compensation process. It allows employers or insurers to formally dispute a claim for benefits. Several other documents share similarities with the WC-3 form in terms of their function and the context in which they are used. Here are five such documents:

  • WC-1 Form: This form is used by employers to report an injury to the State Board of Workers' Compensation. Like the WC-3, it initiates a formal process regarding a claim, but it focuses on reporting rather than disputing the claim.
  • WC-2 Form: The WC-2 is utilized to suspend benefits when an employee's disability is in question. This form is similar to the WC-3 in that it addresses the compensation process but differs in that it does not necessarily involve a dispute over the claim's validity.
  • WC-14 Form: This form is a request for a hearing. When an employee disagrees with a controversion, they can file a WC-14 to seek resolution. This document is similar to the WC-3 in that it is part of the dispute resolution process but serves as a response rather than a notice of controversion.
  • WC-4 Form: The WC-4 is a request for additional medical treatment. It can be used when there is a need for further medical care after an injury. While the WC-3 is about disputing a claim, the WC-4 focuses on the continuation of care, making it a related document in the claims process.
  • WC-5 Form: This form is used to report a change in the employee's condition. Like the WC-3, it is part of the ongoing management of a workers' compensation claim. However, it specifically addresses changes rather than disputing the right to benefits.

Dos and Don'ts

When filling out the Georgia WC-3 form, there are several important considerations to keep in mind. Here is a list of things you should and shouldn't do to ensure the process goes smoothly.

  • Do ensure all information is accurate. Double-check the employee's name, date of injury, and all contact details. Errors can lead to delays.
  • Do provide specific grounds for controversion. Clearly state the reasons for disputing the claim or medical treatment to avoid confusion.
  • Do send copies to all relevant parties. After completing the form, make sure copies are sent to the employee, employer, and any other interested parties.
  • Do file the form on time. Submit the WC-3 form within 21 days of learning about the injury to avoid penalties.
  • Don’t leave any sections blank. Ensure every part of the form is filled out completely. Incomplete forms can be rejected.
  • Don’t use vague language. Avoid general statements. Be precise about the controversion to facilitate understanding.
  • Don’t forget to sign and date the form. An unsigned form is not valid and will not be processed.
  • Don’t delay submission. Timeliness is crucial. Late submissions may result in additional complications or penalties.

By following these guidelines, you can navigate the process more effectively and reduce the likelihood of issues arising. If you have any questions or need assistance, don't hesitate to reach out to the State Board of Workers' Compensation.

Misconceptions

Misconceptions about the Georgia WC-3 form can lead to confusion for both employees and employers. Understanding the facts is essential for navigating the workers' compensation process. Below are seven common misconceptions:

  • The WC-3 form is only for employers. This is incorrect. While it is primarily filed by employers or insurers to contest a claim, employees also have the right to understand its implications regarding their benefits.
  • Filing the WC-3 form automatically denies a claim. This misconception overlooks the fact that the form serves as a notice of intent to contest specific aspects of a claim, not an outright denial of all benefits.
  • All claims must be controverted using the WC-3 form. Not true. The WC-3 is specifically for cases where compensation is being contested. Other forms, like the WC-2, may be used for different purposes, such as suspending benefits.
  • There is no deadline for filing the WC-3 form. This is misleading. The form must be filed within 21 days of the employer's knowledge of the injury to avoid penalties, including attorney's fees.
  • The WC-3 form can be used to contest any type of claim. This is a misunderstanding. The form is specifically designed for income benefits and does not apply to all types of compensation claims.
  • Once the WC-3 form is filed, the employee cannot respond. This is incorrect. Employees have the right to contest the employer’s notice by filing a different form, such as the WC-14, to request a hearing.
  • Filing a false WC-3 form is a minor issue. This misconception minimizes the seriousness of the matter. Willfully making a false statement can lead to significant penalties, including fines of up to $10,000.

Addressing these misconceptions can help both employees and employers better navigate the complexities of workers' compensation in Georgia.

Key takeaways

When dealing with the Georgia WC-3 form, it is essential to understand its purpose and requirements. Here are some key takeaways that can help you navigate the process effectively:

  • Purpose of the Form: The WC-3 form serves as a notice to controvert a worker's compensation claim, indicating that the employer or insurer disputes the right to compensation.
  • Timeliness is Crucial: It must be filed within 21 days of the employer's knowledge of the injury. Failing to do so may result in penalties or attorney's fees.
  • Specific Grounds Required: The form requires clear identification of the specific grounds for controverting the claim. This includes reasons related to the compensability of medical treatment or the claim itself.
  • Certificate of Service: A copy of the completed form must be sent to the employee, all counsel of record, and any other parties with a financial interest in the claim.
  • Not for All Situations: The WC-3 form cannot be used to suspend benefits solely based on the length of disability. Other forms, such as the WC-2, should be utilized in those cases.
  • False Statements are Serious: Willfully making false statements on the form can lead to severe penalties, including fines up to $10,000 per violation.

By keeping these points in mind, you can ensure that you fill out and use the WC-3 form correctly, thus protecting your rights and responsibilities within the workers' compensation system.