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Georgia workers' compensation cheat sheet

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Type or Print Name Signature Phone Number 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. I. Social Security Number Date of Injury A. IDENTIFYING INFORMATION County of Injury Address EMPLOYEE E-mail Address City Name State Zip Code INSURER/ SELF-INSURER SBWC ID fiv ...

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