Georgia State Board of Workers' Compensation: Attorney Leave of Absence
Georgia State Board of Workers' Compensation: Attorney Leave of Absence
Georgia State Board of Workers' Compensation: Attorney Leave of Absence
Complete this form, and mail it to the State Board of Workers’ Compensation, 270 Peachtree Street, N.W., Atlanta, Georgia 30303-1299
I,
(Attorney’s Name)
Address
Do hereby request that I be granted a leave of absence on cases in which I am counsel of record for the following period(s) of time:
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).