Complete a new Form WC-14 to add an additional employer, insurer or to add date of injury. If you need additional space, do not alter this form, but instead attach additional sheets. Must be typed or printed in black ink.
Please completely fill out the WC-14 EMPLOYEE'S WAGE-REPORT FOR FIFTY-TWO WEEKS FORM. The Delivery Information section below lists various delivery options. Please select the most convenient method and submit the completed form accordingly. Please remember to sign and date the form before submitting it. Delivery Information Delivery by U.S. Mail
Board Forms - State Board of Workers' Compensation
2005年4月1日 · The Board forms are available in a fillable format for printing or downloading a copy to your storage media. If you have any questions, please call the Board’s Call Center at 404-656-3818 or 1-800-533-0682. Beginning October 1, 2024, outdated forms will be returned.
File a Workers’ Compensation Claim - Georgia.gov
Fill out the WC-14 form as completely as possible. Include your name and address and the complete name and address of your employer and their insurance company. You should explain in detail the nature of your injury and what benefits you are seeking.
File a Claim - State Board of Workers' Compensation
The State Board of Workers' Compensation will provide you with Form WC-14 to file a claim or you can get a copy of the WC-14 from the Board's website. If you don't have information on your employer's insurance carrier, call our Coverage Desk at 404- 463-6794 .
Disability Compensation Division | Forms - Hawaii.gov
Ask your employer for a claim form or contact us if your employer does not have the claim form. For employers: TDI-14 Equivalency Tables. TDI-15 TDI Self-Insurer’s Plan Certification and Agreement. TDI-62 This form can only be completed by TDI carriers. Contact your TDI carrier for more information.
Free Georgia Wc 14 Form ⋆ PDF Template
The Georgia WC-14 form, officially named the Notice of Claim, is a critical document for initiating a workers' compensation claim in the state of Georgia. It serves a dual purpose by either notifying the State Board of Workers' Compensation about a claim or requesting a hearing/mediation alongside the notice.
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Form WC-2, WC-3, and WC-14 - Perkins Studdard Workers Comp Attorneys at …
2013年10月31日 · Notice of Claim/Request for Hearing/Request for Mediation (Form WC-14) The most common use of a Form WC-14 is to request a hearing in front of an Administrative Law Judge at the Georgia State Board of Workers’ Compensation. Hearings decide controversies or disagreements between injured workers and their employers about workers’ compensation ...
Fill in a Valid Georgia Wc 14 Template Here Georgia PDF Forms
The Georgia WC-14 form, officially known as the Notice of Claim, plays a crucial role in the Georgia State Board of Workers' Compensation system. It is used by employees to notify the board of a work-related injury or to request a hearing or mediation regarding their workers' compensation claim.
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State Board of Workers' Compensation
Download the WC-14 form from the State Board of Workers' Compensation website.
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