2025 Code of Georgia
Title 34 - Labor and Industrial Relations (Chs. 1 — 15)
Appendix A - Rules and Regulations of the State Board of Workers’ Compensation
Rule 61 - Publication of Notice of Operation Under the Act; Forms
(a) All employers operating under the Georgia Workers’ Compensation Law shall post notice as hereinafter provided upon durable material publicly and permanently in a conspicuous place in each business location. The Board’s website address is www. sbwc. georgia. gov. Upon request, the Board will furnish suitable notices free of charge. The notice shall be in such form that it can be understood by all employees and read as follows:
- This business operates under the Georgia Workers’ Compensation Law. WORKERS MUST REPORT ALL ACCIDENTS IMMEDIATELY TO THE EMPLOYER BY ADVISING THE EMPLOYER PERSONALLY, OR AN AGENT, REPRESENTATIVE, BOSS, SUPERVISOR OR FOREMAN OF THE EMPLOYER. If the worker is hurt or injured at work, the employer/insurer shall pay medical and rehabilitation expenses within the limits of the law. In some cases, the employer will also be required to pay a part of the worker’s lost wages. Work injuries and occupational diseases should be reported in writing whenever possible. The worker may lose the right to receive compensation if an accident is not reported within 30 days.
- The employer will supply free of charge, upon request, a form for reporting accidents and will also furnish, free of charge, information about workers’ compensation. The employer will also furnish to the employee, upon request, copies of Board forms on file with the employer pertaining to an employee’s claim.
The Board may excuse lack of notice of injury if the employer does not follow the foregoing requirements for posting notice. [O. C. G. A. § 34-9-80]
- This business operates under the Georgia Workers’ Compensation Law. WORKERS MUST REPORT ALL ACCIDENTS IMMEDIATELY TO THE EMPLOYER BY ADVISING THE EMPLOYER PERSONALLY, OR AN AGENT, REPRESENTATIVE, BOSS, SUPERVISOR OR FOREMAN OF THE EMPLOYER. If the worker is hurt or injured at work, the employer/insurer shall pay medical and rehabilitation expenses within the limits of the law. In some cases, the employer will also be required to pay a part of the worker’s lost wages. Work injuries and occupational diseases should be reported in writing whenever possible. The worker may lose the right to receive compensation if an accident is not reported within 30 days.
(b) The Board furnishes, upon request, copies of forms required by law. Use originals of the forms or approved copies of the original forms. The text and format of a Board form may not be altered, except with the specific written permission of the Executive Director. Generally, when filing any Board form or document with the Board, file only the original and no copies. Do not use tabs to separate documents.
- ANYONE FILING A BOARD FORM MUST USE THE MOST CURRENTLY REVISED VERSION OF THE FORM. INSTRUCTIONS ON THE BACK OF ANY BOARD FORM SHALL BE SENT TO THE EMPLOYEE AND SHALL NOT BE FILED WITH THE BOARD.
- Pleadings, forms, documents, or other filings shall be filed with the Board electronically through ICMS or EDI, unless otherwise authorized in these Rules. Whenever an attachment to a filing or submission is required, the employer/insurer shall simultaneously electronically file or mail to the Board a copy of the form and the attachment. Pursuant to Board Rule 60(c), all attachments filed with the Board shall contain the employee’s name, date of injury, and Board claim number. Any attachment that does not contain this information may be rejected by the Board.
- ANY FORM FILED WITH THE BOARD IN ICMS, THROUGH EDI OR IN PAPER MUST ALSO BE PROPERLY SERVED ON THE OPPOSING PARTY BY ELECTRONIC MAIL BY THE FILING PARTY. WHENEVER ELECTRONIC MAIL IS NOT AVAILABLE, SERVICE SHALL BE BY UNITED STATES MAIL. NOTICES OF FILINGS GENERATED BY ICMS DO NOT CONSITUTE PROPER SERVICE OF FORMS FILED WITH THE BOARD. THE EMPLOYER, INSURER, SELF-INSURER, GROUP SELF-INSURER OR THEIR LEGAL REPRESENTATIVE SHALL COMPLETELY FILL OUT THE FORM WC-1 AND FAILURE TO PROVIDE THE VALID NAME AND ADDRESS OF THE EMPLOYEE, EMPLOYER, INSURER, SELF-INSURER, OR GROUP SELF-INSURER (INCLUDING THE INSURER 5-DIGIT SBWC ID NUMBER), DATE OF INJURY, THE EMPLOYEE’S DATE OF BIRTH, AND THE COMPLETION OF SECTIONS B, C, OR D MAY RESULT IN THE REJECTION OF THE FILING WITH THE BOARD.
(1) Form WC-1. Employer’s First Report of Injury. Employers shall complete Section A immediately upon knowledge of an injury and submit the form to their insurer.
- Insurers, self-insurers or group self-insurers who receive a Form WC-1 from an employer shall clearly stamp or otherwise indicate the date of receipt on the form. Insurers, self-insurers or group self-insurers shall complete Section B, C, or D and file the original with the Board and furnish a copy to the employee within 21 days of the employer’s knowledge of disability, injury or death. In accepted catastrophic claims, Form WC-1 shall be filed within 48 hours of the employer’s acceptance of a catastrophic injury as compensable. Complete Section B when the insurer/self-insurer/group self-insurer commence payment of weekly benefits or when the employer continues to pay salary during compensable disability and when employer/insurer suspend for an actual return to work prior to the filing of Form WC-1. Complete Section C in accordance with subsection (d) of O. C. G. A. § 34-9-221 when employer/insurer controverts payment of compensation. Furnish copy to employee and, upon request, to any other person with a financial interest in the claim. Complete Section D when no indemnity benefits are due and/or the claim has not been controverted.
(2) Form WC-2. Notice of Payment or Suspension of Benefits. File Form WC-2 to commence, suspend, or amend the weekly benefit payment under O. C. G. A. § 34-9-261, O. C. G. A. § 34-9-262, or O. C. G. A. § 34-9-263, including payment of salary for compensability, or when a change in disability status occurs after Form WC-1 has been properly filed with the Board. File when suspending O. C. G. A. § 34-9-261 benefits and commencing O. C. G. A. § 34-9-262 benefits pursuant to § 34-9-104(a)(2). Serve a copy of the Form WC-2 and attachments, if any, on the employee and the employee’s attorney, if one has been retained. See, Rule 221. If the last payment is intended to close the case, file final Form WC-4 with the Board.
(3) Form WC-2A. Notice of Payment or Suspension of Death Benefits. Use in death case in lieu of Form WC-2. Use when change in dependency occurs. Use this form when making a payment to the State of Georgia for no dependents.
(4) Form WC-3. Notice to Controvert. Complete Form WC-3 to controvert when a Form WC-1 has previously been filed. Furnish copies to employee and any other person with a financial interest in the claim including, but not limited to, the treating physician(s) and attorney(s) in the claim. See subsections (d), (h), and (i) of O. C. G. A. § 34-9-221 and Rule 221.
(5) Form WC-4. Case Progress Report. File as follows:
(A) In all claims, within one year of the first date of disability, injury or death;
(B) Within 30 days from last payment for closure;
(C) Upon request of the Board;
(D) Every 12 months from the date of the last filing of a Form WC-4 on all open cases;
(E) To reopen a case;
(F) Within 30 days of final payment made pursuant to an approved stipulated settlement;
(G) Within 90 days of receipt of an open case by the new third party administrator.
(6) Form WC-6. Wage Statement. File when the weekly benefit is less than the maximum under O. C. G. A. § 34-9-261 or § 34-9-262 and furnish a copy to the employee. If a party makes a written request of the employer/insurer, then the employer shall send the requesting party a copy of the Form WC-6 within 30 days.
(7) Form WC-10. Notice to Elect or Reject Coverage. A sole proprietor or partner must file this form to elect coverage under the provisions of O. C. G. A. § 34-9-2.2.
- The employer must file this form in order that the corporate officer or limited liability company member be exempt from coverage, or to revoke their previously filed exemption. Rejection becomes effective the date of filing with the insurer. Where the employer has workers’ compensation insurance coverage, the employer must send this form to their workers’ compensation insurer. If no workers’ compensation coverage is in place, file this form with the Board. The farm labor employer must file this form in order to request coverage for farm laborers, or to revoke their previously filed request.
(8) Form WC-11. Standard Coverage Form.
(9) Form WC-12. Request for Copy of Board Records. Any party requesting a copy of Board records shall file their request on this form. The Board’s file will include any document or form submitted by the parties to a claim or any document transmitted by the Board. Any party who receives a copy of a Board record pursuant to their request shall pay the charges due within 30 days of receipt of an invoice from the Board.
(10) Form WC-14. Notice of Claim/Request for Hearing or Mediation. File to provide notice of a claim, request a hearing, or request a mediation conference. The employee or employee’s attorney shall completely fill out the Form WC-14 and must provide the valid name and address of the employee, employer, insurer, self-insurer or group insurer (including the insurer 5-digit SBWC ID number), date of injury, employee’s date of birth, and other information as stated on the Form WC-14. Specific body parts injured must be listed on the WC-14. Furnish a copy of Form WC-14 to all other parties, per Rule 60(j) and Rule 61(b). WC-14s filed on paper that are rejected by the Board due to insufficient information for processing shall retain the original filing date if the WC-14 (showing the original filing date) is properly completed and returned to the Board.
(11) Form WC-14A. Request to Change Information on a Previously Filed Form WC-14. The following information can be changed on this form: the date of injury (plus or minus 30 days from the date of injury on the WC-14), correction of an employer’s name, dismissal of an employer, insurer, self-insured employer, or claims office. Hearing/mediation issues may also be added on this form (This form can only be filed by the party who filed the WC-14.) A form WC-14A shall not be used to change an address of record, add additional parties, or additional dates of injury. A new Form WC-14 shall be filed with the Board to add an additional date of injury, to add or amend any information pertaining to the employer, insurer, self-insured employer, claims office, or part of body injured.
(12) Form WC-15. Attorney Certification for No-Liability Stipulated Settlements. Must be attached to all no-liability stipulated settlements.
(13) Form WC-20(a). Medical Report. This report and/or the 1500 Claim Form, and/or UB-04 shall be completed and filed as follows:
(A) The attending physician or other practitioner makes the report and forwards it along with office notes and other narratives to the employer/insurer as follows:
(i) Within seven days of initial treatment;
(ii) Upon the employee’s discharge by the attending physician;
(iii) At least every three months until the employee is discharged;
(iv) Upon the employee’s release to return to work;
(v) When a permanent partial disability rating is determined.
(vi) Pursuant to Rule 203(b).
(B) The employer/insurer shall file the report including office notes and narratives with the Board within 10 days after receipt as follows:
(i) When the report contains a permanent partial disability rating;
(ii) Upon request of the Board; and,
(iii) To comply with other rules and regulations of the Board.
(C) The employer/insurer shall maintain copies of all medical reports and attachments in their files and shall not file medical reports except in compliance with this rule and Rule 200(c).
(14) Form WC-24. Enforcement Division Request for Board Intervention. For use by Enforcement Division only.
(15) Form WC-25. Application for Lump Sum/Advance Payment. See Board Rule 222.
(16) Form WC-26. Consolidated Yearly Report of Medical Only Claims and Annual Payments on Indemnity Claims. File on or before March 1st following each calendar year in respect to all medical and indemnity payments for the previous year for work-related injuries. File annually even if no reportable payment occurred during the reporting year.
(17) Form WC-100. Request for Settlement Mediation. To be used when a party is requesting a settlement mediation.
(18) Form WC-102. Request for Documents from Parties. Prior or subsequent to a hearing being requested in a claim, the parties shall be entitled to request copies of documents listed in this form from the opposing parties, and the named documents shall be provided to the requesting party within 30 days of the date of certificate of service, subject to penalties for failure to comply.
(19) Form WC-102B. Notice of Representation by an attorney for an employer, insurer, or party-at-interest. A claimant’s attorney shall file a notice of representation by filing their attorney fee contract in compliance with Board Rule 108.
(20) Form WC-102C. Attorney Leave of Absence. An attorney who is counsel of record, and wishes to obtain a Leave of Absence, must file this form with the Atlanta office of the Board. If granted, the leave will cover all cases for which the attorney is counsel of record which are not calendared on the date of approval.
(21) Form WC-102D. Motion/Objection to Motion. A party who makes or objects to a motion shall use this form, if no other specific Board form exists for the motion or request, and shall serve a copy on all counsel and unrepresented parties.
(22) Form WC-104. Notice to Employee of Medical Release to Return to Work with Restrictions or Limitations. For non-catastrophic accidents occurring on or after July 1, 1992, the employer/insurer shall send this form to the employee no later than 60 days after the medical release of the employee to return to work with restrictions or limitations.
(23) Form WC-108a. Attorney Fee Approval. An attorney shall file this form in order to request approval of a fee contract, an assessed fee by consent, and for resolution of a fee lien dispute by consent, when there is no pending litigation, and shall serve a copy on all counsel and unrepresented parties.
(24) Form WC-108b. Attorney Withdrawal/Attorney Fee Lien. An attorney who is terminated or wishes to withdraw must file this form and follow the procedures set out in Rule 108(d)-(e). An attorney of record who chooses to file a lien for services and/or request for reimbursement of expenses after withdrawal from representation or after services are terminated, in writing, by a client, shall file this form with supporting documentation, and serve a copy on all counsel and unrepresented parties.
(25) Form WC-121. Change of TPA Claims Office/Servicing Agent. An insurer, self-insurer, or self-insurance fund shall file this form to give: 1) notice of the employment of a claims office; 2) change an address of a claims office; 3) add additional claims offices; and 4) notice of the termination of services of a claims office.
(26) Form WC-131. Permit to Write Insurance. Insurers shall complete this form and file it with the Board to receive a permit to write workers’ compensation insurance in the state of Georgia.
(27) Form WC-131(a). Permit to Write Insurance Update. Insurers shall complete this form annually and file it with the Board when updating a permit to write workers’ compensation insurance in the state of Georgia.
(28) Form WC-200a Change of Physician/Additional Treatment by Consent. Parties who agree on a change of physician/additional treatment shall file a properly executed Form WC-200a with the Board, with copies provided to the named medical provider(s) and parties to the claim, which form shall be deemed to be approved and made the order of the Board pursuant to O. C. G. A. § 34-9-200(b) unless otherwise ordered by the Board. A Form WC-200a shall be rejected by the Board if a Form WC-1 or WC-14 has not been previously filed by any party or attorney creating a Board claim.
(29) Form WC-200b. Request/Objection for Change of Physician or Additional Treatment. A party who requests a change of physician or additional treatment without consent, or who objects to a request which has been made, shall file this form with the Board, and serve a copy on all counsel and unrepresented parties. Objections must be filed within 15 days of the date on the certificate of service on the request.
(30) Form WC-205. Request for Authorization of Treatment or Testing by Authorized Medical Provider. Authorized medical providers seeking approval for treatment or testing shall send this form by facsimile or e-mail directly to the insurer/self-insurer who must fax or e-mail a response within five business days. Neither the request nor response shall be filed with the Board, unless otherwise requested.
(31) Form WC-206. Reimbursement Request of Group Health Insurance Carrier/Healthcare Provider. A group health insurance carrier or health care provider which requests reimbursement of medical expenses shall file this form during the pendency of a claim and serve a copy on all counsel and unrepresented parties.
(32) Form WC-207. Authorization and Consent to Release Information. Employer/insurers seeking the release of medical information pursuant to O. C. G. A. § 34-9-207 may utilize this form to receive consent from the employee.
(33) Form WC-208a. Application for certification of WC/MCO.
(34) Form WC-226(a). Petition for Appointment of Temporary Conservatorship of Minor. A party petitioning for the Board to appoint a temporary conservator to receive and administer workers’ compensation benefits for a minor may file this form with the WC-14 or when submitting a settlement agreement and shall serve a copy on all counsel and unrepresented parties.
(35) Form WC-226(b). Petition for Appointment of Temporary Conservatorship of Legally Incapacitated Adult. A party petitioning for the Board to appoint a temporary conservator to receive and administer workers’ compensation benefits for a legally incapacitated adult may file this form with the WC-14 or when submitting a settlement agreement and shall serve a copy on all counsel and unrepresented parties.
(36) Form WC-240. Notice to Employee of Offer of Suitable Employment. The employer/insurer shall use this form to notify an employee of an offer of employment which is suitable to his/her impaired condition as required by O. C. G. A. § 34-9-240, and shall provide it to the employee and his/her attorney at least 10 days prior to the date the employee is scheduled to return to work. File this form as an attachment to a Form WC-2 when unilaterally suspending income benefits under Board Rule 240.
(37) Form WC-240A. Job Analysis. An employer/insurer may use this form in conjunction with a Form WC-240 to provide a detailed job description when notifying an employee of an offer of employment which is suitable to his/her impaired condition as required by O. C. G. A. § 34-9-240, and shall provide it to the employee and his/her attorney at least 10 days prior to the date the employee is scheduled to return to work. Attach this form with a Form WC-240 and file it with the Form WC-240 as an attachment to a Form WC-2 when unilaterally suspending income benefits under Board Rule 240.
(38) Form WC-243. Credit. An employer/insurer seeking a credit pursuant to O. C. G. A. § 34-9-243 shall file this with the Board and send a copy to all counsel and unrepresented parties. The employer/insurer must specify the amount of unemployment compensation and/or income payments made to the employee pursuant to a disability plan, a wage continuation plan, or a disability insurance policy, and shall specify the ratio of the employer’s contributions to the total contributions of such plan or policy.
(39) Form WC-244. Reimbursement Request of Group Insurance Carrier/Disability Benefits Provider. A group insurance carrier or disability benefits provider which requests reimbursement of disability benefits shall file this form during the pendency of a claim, and serve a copy on all counsel and unrepresented parties.
(40) Form WC-262. Payment of Temporary Partial Disability Income Benefits. Upon payment of any temporary partial disability income benefits under O. C. G. A. § 34-9-262 to an employee based on an actual return to work, an employer shall file this form with the Board and send a copy to the employee and counsel, if represented.
(41) Form WC-Change of Address. This form is to be used only to change certain addresses of record. For employers and attorneys, this form only needs to be filed once as this form will change information in every claim. Do not file this form if a party’s address is correct, but improperly listed in a claim.
(42) Form WC-PMT. Use this form to request approval of recommended medical treatment or testing by an authorized medical provider.
(43) Form WC-PMT(b). Use this form to request an employee to attend an appointment with an authorized medical provider.
(44) Form WC-Request to Change Information. File this form to correct the employee’s name, date of birth, correct the county of injury and to correct a claims office that has been listed incorrectly in a claim. (This form can be filed by any party.)
(45) Form WC-R1. Request for Rehabilitation. The employer/insurer shall file:
(A) Within 48 hours of the employer’s acceptance of a catastrophic injury as compensable, simultaneously with the Form WC-1, naming a catastrophic supplier;
(B) Within 15 days of notification that rehabilitation is required to request a rehabilitation supplier;
(C) When the employer/insurer requests a supplier for cases with dates of injury prior to July 1, 1992;
(D) When the employer/insurer requests a change of supplier;
(E) To request reopening of rehabilitation; or
(F) Upon request of the Board.
The employee or employee’s attorney shall file a Form WC-R1 to request appointment of a supplier for cases with dates of injury prior to July 1, 1992, for change of supplier or reopening of rehabilitation. A case party shall file a Form WC-R1 when a stipulated settlement provides for rehabilitation and rehabilitation is not already on the case. A case party may file a Form WC-R1 to request an extension of vocational rehabilitation services for cases with dates of injury prior to July 1, 1992. All required information shall be supplied and shall be legible. The certificate of service must be completed and the date mailed must be indicated.
(46) Form WC-R1CATEE. Employee Request for Catastrophic Designation. The employee or employee’s attorney shall file:
(A) If the employer/insurer fail to timely designate the claim catastrophic and the employee believes the case to qualify for catastrophic designation;
(B) With supporting documentation;
(C) Presenting a choice for a Board Certified catastrophic rehabilitation supplier.
(47) Form WC-R2. Rehabilitation Transmittal Report.
- The principal rehabilitation supplier shall file:
(A) To accompany updated narrative progress reports on catastrophic cases every 90 days;
(B) To prepare for a rehabilitation conference;
(C) Progress reports as required by the Board not submitted with a Form WC-R2A and when a stipulation request has been submitted;
(D) Upon request of the Board;
(E) To report medical care coordination services for non-catastrophic cases with dates of injury prior to July 1, 1992.
(48) Form WC-R2A. Individualized Rehabilitation Plan. The principal rehabilitation supplier shall file within 90 calendar days from the date of appointment; not later than 30 calendar days prior to the end of the current rehabilitation period to request extension of services, or to amend an approved plan 30 calendar days prior to the date of plan expiration.
(49) Form WC-R3. Request for Rehabilitation Closure. The principal rehabilitation supplier shall file this form, accompanied by a closure report and any necessary documentation:
(A) Following 60 days of return to work status;
(B) When further services are not needed or feasible;
(C) When a stipulated settlement has been approved by the Board that does not include further rehabilitation services; or
(D) When the Board has closed the case any party may file to request closure of rehabilitation accompanied by documentation supporting the request.
(50) Form WC-R5. Request for Rehabilitation Conference. Any party or principal rehabilitation supplier may file to request a rehabilitation conference.
(51) Form WC-Rehabilitation Registration Application. Application to be a licensed rehabilitation supplier. File this form with the Board to be a certified rehabilitation supplier in the state of Georgia.
(52) Form WC-Rehabilitation Registration Application Renewal. Application to renew certification for a licensed rehabilitation supplier. File this form annually with the Board to renew certified rehabilitation supplier status in the state of Georgia.
(53) Form WC-Catastrophic Rehab Release. To be utilized only by employers/insurers contracted with a Board Certified Managed Care Organzation. See Board Rule 201.
(54) Form Rehab Obj. Any party who has an objection to any issue related to rehabilitation services must timely file this form with supporting documentation attached. Timely filing is within 20 days of the certificate of service of a WC-R1; WC-R1CATEE; WC-R2; WC-R2A; or WC-R3.
(55) Form WC-P1. Panel of Physicians. See Board Rule 201.
(56) Form WC-P3. WC/MCO Panel. To be utilized only by employers/insurers contracted with a Board Certified Managed Care Organization. See Board Rule 201.
(57) Form WC-Bill of Rights. Bill of Rights. Use and post with the panel of physicians (Form WC-P1 or WC-Form P3). See O. C. G. A. § 34-9-81.1 & Board Rule 81.1.
(58) Form WC-Subpoena. Use this form for hearings. Do not file subpoenas with the Board. Subpoenas shall be produced at the hearing or attached to a motion only when enforcement or a postponement is at issue.
(59) Any party or attorney filing a form with the Board shall use the most current version of the form. In addition, no party or attorney shall submit any form that has been discontinued or altered. A violation of this rule may result in the rejection of the filing with the Board, and/or the imposition of a civil penalty under O. C. G. A. § 34-9-18.
(60) When electronically filing any form with the Board, and when required by Statute, Rule, or form to serve a copy on an opposing attorney or party, a copy of the form or the ICMS equivalent of the form filed may be used for service.
(61) Service upon a party or attorney of any form, document, or other correspondence shall be by electronic mail. Whenever electronic mail is not available, service shall be by U. S. Mail.
(62) All forms, documents, or other correspondence should be filed electronically through ICMS web submission or EDI, if available.
(63) No party or attorney shall use the ICMS doc-type “Misc” when requesting any action by the Board. This doc-type shall only be used when no action is being requested.
(64) A pro-se party must file correspondence, documents or forms in paper with any Board office. A document may be filed via facsimile transmission. Any filing by facsimile transmission must be clearly labeled with the name of the claimant, claim number, and Board division or employee to whom the facsimile transmission is directed.
Annotations
Notes
Note as to revisions.The revision effective July 1, 1996, rewrote this rule.
The revision effective July 1, 1997, substituted “Board” for “board” throughout this rule; and, in subsection (b), in paragraph (5), deleted former subparagraph (A), which read: “When an actual return to work occurs (attach to Form WC-2 when suspending benefits)”, redesignated former subparagraphs (B) through (G) as subparagraphs (A) through (F), and added present subparagraph (G); in paragraph (11), deleted “/Notice of Representation” from the end of the paragraph head and deleted “of representation of any party other than the claimant by an attorney” from the end of the first sentence; added present paragraph (24) and redesignated former paragraphs (24) through (28) as paragraphs (25) through (29), deleted former paragraph (29), and added “on the request” at the end of paragraph (31).
The revision effective July 1, 1998, in subsection (b), substituted “copies of the original forms” for “color coded facsimiles” at the end of the first sentence; throughout the subsection set out the paragraph catchlines, in paragraphs (1) through (5), (9), (12), (15) through (18), and (28) changed the color of paper to White; and substituted “Upon request of the Board” for “When the Board requests it” in subparagraph (F) of paragraph (15).
The revision effective July 1, 1999, rewrote this rule.
The revision effective July 1, 2001, added new paragraph (12) and redesignated paragraphs (12) through (32) as (13) through (33), added new paragraph (34) and redesignated paragraphs (33) through (35) as paragraphs (35) through (37), and added new paragraphs (38) and (39) and redesignated paragraphs (36) through (38) as paragraphs (40) through (42).
The revision effective July 1, 2002, deleted former paragraph (7) which read: “Form WC 7 (Color of paper: White). Application for Self Insurance.”; redesignated former paragraphs (8) through (17) as present paragraphs (7) through (16); in paragraph (13) substituted “Enforcement” for “Fraud and Compliance” throughout; added paragraphs (17) and (24); redesignated former paragraphs (24) through (40) as present paragraphs (25) through (41); added paragraph (42); redesignated former paragraphs (41) and (42) as present paragraphs (43) and (44); in paragraph (11) substituted “Certification” for “Affidavit”; in subparagraph (18)(A) substituted “90 days” for “60 days”; in paragraph (26) substituted “WC 102D” for “WC 102g”; in paragraph (27) substituted “WC 102B” for “WC 102i”; and in paragraph (28) substituted “WC 102C” for “WC 102j”.
The revision effective July 1, 2003, inserted “or when the employer continues to pay salary during compensable disability” in the first sentence of the undesignated paragraph following paragraph (b)(1); inserted “, including payment of salary for compensability,” in the first sentence of paragraph (b)(2); substituted “Within 180 days of the first date of disability” for “Not later than the ninetieth day of disability” in subparagraph (b)(5)(A); substituted “With all settlement documents.” for “With all no liability settlement documents, and other settlement documents for which a claim will be immediately closed upon approval.”; inserted “and/or the HCFA 1500, HCFA 1450, and/or UB92” in paragraph (b)(12); and added division (b)(12)(A)(vi).
The revision effective July 1, 2004, rewrote subparagraph (b)(5)(F) and added “and shall serve a copy on all counsel and unrepresented parties” to the end of paragraphs (b)(39) and (b)(40).
The revision effective July 1, 2005, rewrote this rule.
The revision effective July 1, 2006, in paragraph (b)(1), added the second sentence in paragraph (b)(1), and added the next-to-last undesignated paragraph; inserted “under O.C.G.A. § 34-9-261, O.C.G.A. § 34-9-262, or O.C.G.A. § 34-9-263” in the middle of the first sentence of paragraph (b)(2); deleted “This form shall not be used to change an address of record.” from the end of paragraph (b)(10); rewrote paragraphs (b)(11) and (b)(25); added paragraphs (b)(26) and (b)(27); redesignated paragraphs (b)(28) through (b)(45) as paragraphs (b)(30) through (b)(47), respectively; in paragraph (b)(28), added the last sentence; in paragraphs (b)(36) and (b)(37), deleted “, filing a copy with the Board” from the end of first sentence, and added the second sentence; rewrote present paragraph (b)(41); added paragraphs (b)(48) and (b)(49); redesignated paragraphs (b)(46) through (b)(49) as paragraphs (b)(50) through (b)(53), respectively; and added paragraphs (b)(54) and (b)(55).
The revision effective July 1, 2007, rewrote subparagraph (b)(5)(F); added present paragraph (b)(50), and redesignated former paragraphs (b)(50) through (b)(55) as paragraphs (b)(51) through (b)(56), respectively.
The revision effective July 1, 2008, deleted “(Color of paper: Pink)” from paragraphs (b)(51) through (b)(54), and added paragraphs (b)(57) through (b)(59).
The revision effective July 1, 2009, in subsection (b), added the last three sentences in the introductory paragraph, in paragraph (b)(9), added the second sentence, in paragraph (b)(16), substituted “March 1st” for “January 31”, added paragraph (b)(55), redesignated former paragraphs (b)(55) through (b)(59) as present paragraphs (b)(56) through (b)(60), respectively, and added paragraph (61).
The revision effective July 1, 2010, in subparagraph (b)(5)(A), substituted “one year” for “180 days”; added the last sentence in paragraph (b)(10); substituted “and/or UB04” for “HCFA 1450, and/or UB92” in the introductory language of paragraph (b)(13); inserted “based on an actual return to work” in paragraph (b)(40); and, in paragraph (b)(61), deleted “, only with the prior express permission of the Board” at the end of the second sentence, and added the third sentence.
The revision effective July 1, 2014, substituted “1500 Claim Form” for “HCFA 1500” in paragraph (b)(13); substituted “Conservatorship” for “Guardianship” and substituted “conservator” for “guardian” in paragraphs (b)(34) and (b)(35); added paragraph (b)(51); and redesignated former paragraphs (b)(51) through (b)(61) as present paragraphs (b)(52) through (b)(62), respectively.
The revision effective February 16, 2016, added paragraph (b)(42); and redesignated former paragraphs (b)(42) through (b)(62) as present paragraphs (b)(43) through (b)(63), respectively.
The revision effective July 1, 2016, in paragraph (b)(2), substituted “Serve a copy of the Form WC-2 and attachments, if any, on the employee and the employee’s attorney” for “Mail a copy of the Form WC-2 and attachments, if any, to the employee and their attorney”; in paragraph (b)(10), deleted “(A request for hearing by an employee will be considered only after the time required of the employer/insurer to make the first payment of income benefits has expired as provided in O.C.G.A. § 34-9-221.)” following “to all other parties” and added “Specific body parts injured must be listed on the WC-14.” at the end.
The revision effective July 1, 2017, deleted “Copies of all filings shall be served on the employee and the employee’s attorney, if represented.” at the end of the first paragraph of subsection (b); added the undesignated paragraph following the first paragraph of subsection (b); rewrote paragraph (b)(11), which formerly read: “A party or attorney shall file this form with the Board when requesting correction of a mistake concerning the employee’s name, social security number, date of injury, or county of injury on a previously filed Form WC-14. A Form WC-14A shall not be used to change an address of record, add additional parties, or additional dates of injury. A new Form WC-14 shall be filed with the Board to add or amend any information pertaining to the employer, the insurer, the servicing agent or part of body injured, and to add an additional date of injury, hearing issue, or mediation issue.”; and rewrote paragraph (b)(42), which formerly read: “This form is to be used to correct an employee’s name, Social Security Number or Board Tracking Number, county of injury or claims office that has been listed incorrectly in a claim.”
The revision effective July 16, 2018, in the second undesignated paragraph of subsection (b), deleted “When filing via Electronic Data Interchange (EDI), and whenever an attachment to a filing or submission is required, the employer, insurer, self-insurer, group self-insurer, or designated claims office (TPAs) shall simultaneously mail to, or electronically file with, the Board the filed Subsequent Report of Injury (SROI) or Form and a copy of such attachment.”, and added the first and second sentences; in the third undesignated paragraph of subsection (b), deleted “OR UNITED STATES MAIL” following “BY ELECTRONIC MAIL” in the first sentence and added the second sentence; deleted former paragraph (b)(54), which read: “Form WC-P2. Conformed Panel of Physicians. See Board Rule 201.”; and redesignated former paragraphs (b)(55) through (b)(63) as present paragraphs (b)(54) through (b)(62), respectively.
The revision effective September 1, 2019, in the third undesignated paragraph of paragraph (b)(1), deleted “the employee’s social security number,” following “date of injury,”; in the undesignated paragraph following (b)(10), deleted the former third sentence, which read: “The employee must furnish a social security number if available, otherwise the Board will assign a tracking number.”; added paragraphs (b)(42) and (b)(43), and redesignated the following paragraphs accordingly; in present paragraph (b)(44), deleted “SSN or Board Tracking Number,” following “employee’s name,”.
The revision effective July 1, 2021, rewrote this rule.
The revision effective July 1, 2023, revised paragraph (b)(24).
The revision effective July 1, 2024, in the first undesignated paragraph of paragraph (b)(1), substituted “FILING” for “USING”; and made editorial changes.
