Employers First Report Of Injury Or Occupational Disease {WC-1}

WC-1 EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE GEORGIA STATE BOARD OF WORKERS' COMPENSATION EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE NOTE: FAILURE TO SUBMIT THIS REPORT TO INSURER IMMEDIATELY MAY RESULT IN PENALTY. MUST BE TYPED OR PRINTED IN BLACK INK. Board Claim No. Employee Last Name Employee First Name M.I. Date of Injury SSN or Board Tracking # A. IDENTIFYING INFORMATION EMPLOYEE Address Name Male Female Birthdate Phone Number City NAICS Code Phone Number State Zip Code Employer E-mail Employee E-mail State Zip Code EMPLOYER Address City Nature of Business (Trade, Transport, Mfg., etc.) Employer FEIN INSURER / SELF-INSURER CLAIMS OFFICE SBWC ID# (five digit no.) Name Name Address Date Hired by Employer Job Classified Code No. Insurer/Self-Insurer FEIN Claims Office FEIN # City Number of Days Worked Per Week Claims Office Phone Insurer/ Self-Insurer File # Claims Office E-mail State Zip Code per Hour per Day per Week EMPLOYMENT/WAGE Insurer Type Code List Normally Scheduled Days Off Wage rate at time of Injury or Disease: ­ Insurer S-Self-insurer Group Fund County of Injury am pm Date Employer had knowledge of Injury per Month Enter First Date Employee Failed to Work a Full Day INJURY/ILLNESS & MEDICAL Did Employee Receive Full Pay on Date of Injury? Yes No Time of Injury Did Injury/Illness Occur on Employer's premises? Yes No Type of Injury/Illness Body Part Affected How Injury or Illness / Abnormal Health Condition Occurred Treating Physician (Name and Address) Initial Treatment Given: None Minor: By Employer Minor: Clinical/Hospital Emergency Room Hospitalized > 24hrs Report Prepared By (Print or Type) Hospital / Treating Facility (Name and Address) If Returned to Work, Give Date: Returned at what wage If Fatal, Enter Complete Date of Death per Week Telephone Number Date of Report B. INCOME BENEFITS Previously Medical Only Form WC-6 must be filed if weekly benefit is less than maximum Date of disability: Yes No Average Weekly Wage: $ Compensation paid: $ FOR: Temporary partial disability Weekly benefit: $ or Date salary paid: Penalty paid: $ Date of first Payment: BENEFITS ARE PAYABLE FROM Temporary total disability Permanent partial disability of % to for weeks. UNTIL WHEN THE EMPLOYEE ACTUALLY RETURNED TO WORK WITHOUT RESTRICTIONS. ALL OTHER SUSPENSIONS REQUIRE THE FILING OF FORM WC-2 WITH THE STATE BOARD OF WORKERS' COMPENSATION AND THE EMPLOYEE. C. NOTICE TO CONTROVERT PAYMENT OF COMPENSATION Benefits will not be paid because: D. MEDICAL ONLY INJURY No disability paid or controverted Signature Date Insurer / Self-Insurer: Type or Print Name of Person Filing Form Phone and Ext. E-mail 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). WC-1 REVISION . 07/2011 1 1 OF 2 EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE American LegalNet, Inc. www.FormsWorkFlow.com WC-1 EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE GEORGIA STATE BOARD OF WORKERS' COMPENSATION NOTICE TO EMPLOYER 1. Provide prompt medical attention; allow the employee to select a physician from your posted panel, and explain the panel to the employee. 2. Complete Section A of this form immediately upon your knowledge of an injury and send the WC-1 to your insurance company or self-insurer claims office. FAILURE TO DO SO MAY RESULT IN A PENALTY. Do not send this form to the State Board of Workers' Compensation. 3. If you need additional help, call your insurance company or self-insurer claims office. 4. Report serious injuries immediately by telephone to your insurer's claims department, then file this form with your insurance company or self-insurer claims office. NOTICE TO INSURER / SELF-INSURER 1. Complete Section B, C, or D. This form must be filed with the State Board of Workers' Compensation. A copy of both sides of this form must be sent to the claimant(s) and all counsel of record. Form W-6 must be filed if weekly benefits are less than the maximum. NOTICE TO EMPLOYEE 1. This form is provided for your information only. If Section B is completed, you will receive income benefits on a weekly basis and the employer will pay medical expenses from approved doctors. If you do not receive payment of benefits, or medical bills are not paid, call your employer or your employer's insurance company or self-insurer claims office. If Section C is completed, your claim of injury has been denied by the employer/insurer. If you disagree with this denial, you must file a form WC-14, Notice of Claim, within one year of the accident with the State Board of Workers' Compensation, 270 Peachtree Street N.W., Atlanta, Georgia 30303-1299. For Information or Assistance, contact: STATE BOARD OF WORKERS' COMPENSATION Toll Free Telephone: 1-800-533-0682 In Atlanta: (404) 656-3818 http://www.sbwc.georgia.gov 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). WC-1 REVISION . 07/2011 1 2 OF 2 EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE American LegalNet, Inc. www.FormsWorkFlow.com