Credit {WC-243}

WC - 243 CREDIT GEORGIA STATE BOARD OF WORKERS' COMPENSATION IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS222 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. 24734-9-18 AND 24734-9-19). WC -243 REVISION 12/2018 243 CREDIT CREDIT Instructions: When seeking credit/reimbursement pursuant to O.C.G.A. 24734-9-243, the employer shall file this form with the State Board of Workers' Board Claim No. Employee Last Name Employee First Name M.I. Date of Injury A. IDENTIFYING INFORMATION EMPLOYEE County of Injury M ailing Address Employee E - mail City State Zip Code EMPLOYER Name INSURER/ SELF-INSURER Name M ailing Address CLAIMS OFFICE Name SBWC ID# (five digit no) E - mail City State Zip Code Mailing Address Employer E - mail Phone Numb er City State Zip Code B. CREDIT REQUESTED 1. A credit is requested as allowed by O.C.G.A. 247 34 - 9 - 243 for benefits paid under the "Employment Security Law" or employer funded portions of payments received by the employee pursuant to: Unemployment compensation payments Wage continuation plan 000211 Disability plan Disability insurance policy 2. The employee has been paid weekly benefits of $ , from the date of / / through / / , for which credit is sought. 3. The ratio of the employer222s contributions to the total contributions of the plan or policy is %. The amount of credit per week will be calculated as follows: $ X % = $ ( weekly disability benefit per plan or policy) (Ratio of contributions) (to be credited against TTD or TPD benefits due.) Credit shall not exceed the amount of income benefits due the employee. C. CERTIFICAT E OF SERVICE I hereby certify that the above information is true and correct to the best of my knowledge and a copy of this form has been sent to the Board, to counsel, and to all unrepresented parties in this claim. Print Name Here Signature Date Phone E - mail