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WC-121 CHANGE OF TPA / SERVICING AGENT GEORGIA STATE BOARD OF WORKERS' COMPENSATION CHANGE OF TPA / SERVICING AGENT Instructions: An insurance carrier/self-insurer/group fund shall file this form
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How to fill out georgia wc 121 form
How to fill out Georgia wc 121 form:
01
Obtain a copy of the Georgia wc 121 form either online or from the Georgia State Board of Workers' Compensation.
02
Begin by providing your personal information, such as your name, address, and contact details.
03
Fill in the information regarding your employer, including their name, address, and contact information.
04
Indicate the date and time the injury or illness occurred, as well as the location where it happened.
05
Describe the nature of the injury or illness in detail, including any specific body parts affected.
06
Provide information about any medical treatment received, including the names of healthcare providers and facilities.
07
Include details about any previous workers' compensation claims you have made.
08
If applicable, provide information about any witnesses to the incident.
09
Sign and date the form, certifying that the information provided is accurate and complete.
Who needs Georgia wc 121 form:
01
Employees who have suffered a work-related injury or illness in the state of Georgia.
02
Employers who need to report and document worker's compensation claims.
03
Healthcare providers who have treated patients with work-related injuries or illnesses in Georgia.
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Who is required to file georgia wc 121 form?
Employers in the state of Georgia who are subject to the state's workers' compensation laws are required to file the Georgia WC 121 form.
How to fill out georgia wc 121 form?
The Georgia WC 121 form is a form used to report a workplace injury or illness to the Georgia State Board of Workers' Compensation. The form must be completed by the employer and sent to the Board within seven days of the injury or illness.
To fill out the Georgia WC 121 form, begin by providing the employer's contact information, including name, address, phone number, and email address. Next, provide the injured worker's contact information, including name, address, and date of birth.
On the next page, provide details about the injury or illness, including the date of the incident, the nature of the injury or illness, and the body part(s) affected.
On the following page, provide information about the worker's medical care, including the name of the treating physician and the dates of any visits.
Finally, provide the names of any witnesses on the next page and sign the form to certify that the information provided is true and accurate.
What is the purpose of georgia wc 121 form?
The Georgia WC-121 form is an Employer's Report of Injury or Occupational Disease for Workers' Compensation. This form must be completed by employers when an employee is injured or becomes ill as a result of their job. It is used to provide information to the Georgia State Board of Workers' Compensation so that the employee may be eligible to receive workers' compensation benefits.
What information must be reported on georgia wc 121 form?
The Georgia WC 121 form requires employers to report the following information:
1. Employer name
2. Employer address
3. Employer telephone number
4. Employer Federal ID number
5. Employer's State of Georgia ID number
6. Date of injury
7. Employee name
8. Employee address
9. Employee Social Security number
10. Type of injury or illness
11. Nature of injury or illness
12. Date of diagnosis or treatment
13. Name and address of doctor, hospital, or other health care provider
14. Information regarding time lost from work, and when the employee is expected to return
15. Information regarding any other benefits the employee has received, such as Social Security or workers' compensation
16. Employer's signature and title
17. Date signed
When is the deadline to file georgia wc 121 form in 2023?
The Georgia WC-121 form must be filed within 30 days of the date of injury or the date the employee knew or should have known that their injury was work-related. Therefore, the deadline to file the form in 2023 will depend on when the injury occurred.
What is the penalty for the late filing of georgia wc 121 form?
The penalty for the late filing of Georgia WC 121 form is a fine of up to $500.
What is georgia wc 121 form?
The Georgia WC-121 form is a document used for reporting an injury or illness in the workplace. It is also referred to as the "Employer's First Report of Injury or Occupational Disease." This form must be completed by the employer within 21 days from the date they were notified of the injury or the date the injury occurred. It includes information about the injured employee, details about the injury or illness, and information about the employer and insurance coverage. The completed form is then submitted to the Georgia State Board of Workers' Compensation.
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