WC 102b
WC 102b
WC 102b
A. IDENTIFYING INFORMATION
County of Injury Address
EMPLOYEE
Employee E-mail City State Zip Code
ATTORNEY FOR Name Name
EMPLOYEE / EMPLOYER
CLAIMANT
Address Address
City State Zip Code City State Zip Code
GA Bar number Employer E-mail
Attorney E-mail Name
INSURER /
SELF-INSURER
PARTY AT Name Name
INTEREST CLAIMS OFFICE
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:
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).
Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.
Alternative Proxies: