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    WC R5

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    jeffdandel
    This document is a request for a rehabilitation conference filed with the Georgia State Board of Workers' Compensation. It provides identifying information for the employee, employer, insurer, rehabilitation supplier, attorneys, and issues to be discussed. Upon completion, the form must be certified as being sent to all parties and the State Board. Making false statements on the form is a crime under Georgia law.

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    WC R5

    Uploaded by

    jeffdandel
    88 views1 page
    This document is a request for a rehabilitation conference filed with the Georgia State Board of Workers' Compensation. It provides identifying information for the employee, employer, insurer, rehabilitation supplier, attorneys, and issues to be discussed. Upon completion, the form must be certified as being sent to all parties and the State Board. Making false statements on the form is a crime under Georgia law.

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    WC-R5

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    This document is a request for a rehabilitation conference filed with the Georgia State Board of Workers' Compensation. It provides identifying information for the employee, employer, insurer, rehabilitation supplier, attorneys, and issues to be discussed. Upon completion, the form must be certified as being sent to all parties and the State Board. Making false statements on the form is a crime under Georgia law.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    88 views1 page

    WC R5

    Uploaded by

    jeffdandel
    This document is a request for a rehabilitation conference filed with the Georgia State Board of Workers' Compensation. It provides identifying information for the employee, employer, insurer, rehabilitation supplier, attorneys, and issues to be discussed. Upon completion, the form must be certified as being sent to all parties and the State Board. Making false statements on the form is a crime under Georgia law.

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    WC-R5 REQUEST FOR REHAB CONFERENCE

    GEORGIA STATE BOARD OF WORKERS' COMPENSATION


    REQUEST FOR REHAB CONFERENCE
    Submitted by: Claimant Employer / Insurer Supplier

    Board Claim No. Employee Last Name Employee First Name M.I. Social Security Number Date of Injury

                                     

    A. IDENTIFYING INFORMATION
    Phone Number County of Injury Name
    EMPLOYEE             EMPLOYER      
    Address Address Phone Number
                     
    City State Zip Code City State Zip Code
                                      
    Employee E-mail Employer E-mail
               
    Name Name
    REHAB INSURER /
    SUPPLIER       SELF-INSURER      
    Address Phone Number Name
                CLAIMS OFFICE      
    Registration Number Address Phone Number
                     
    City State Zip Code City State Zip Code
                                      
    Supplier E-mail Claims E-mail SBWC ID# (five digit no)
                     
    Name Name
    ATTORNEY FOR ATTORNEY FOR
    EMPLOYEE / CLAIMANT       EMPLOYER / INSURER      
    Address Phone Number Address Phone Number
                           
    City State Zip Code City State Zip Code
                                      
    GA Bar number GA Bar number
               
    Attorney E-mail Attorney E-mail
               

    B. ISSUES:
         

    C. CERTIFICATE OF SERVICE
    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
    Print Name Here Telephone Number

               
    Signature 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-R5 REVISION . 07/2007 R5 REQUEST FOR REHAB CONFERENCE

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