Case Progress Report {WC-4}

WC-4 CASE PROGRESS REPORT GEORGIA STATE BOARD OF WORKERS' COMPENSATION CASE PROGRESS REPORT (File per Board Rule 61(b)5) Initial Board Claim No. Employee Last Name Supplement Employee First Name Final Reopened M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION Name Insurer /Self Insurer File Number SBWC ID# (five digit no.) Date of Final Weekly Payment EMPLOYER B. PAYMENT TYPE Enter actual amounts paid (a) Temporary Total (b) Temporary Partial (c) Permanent Partial (d) Death (e) Stipulation/Settlement (f) Advances RATE WEEKS DAYS TOTAL PAYMENTS C. PAYMENTS 1 2 3 4 5 6 7 8 9 10 11 Total Weekly Benefits Physician Benefits Hospital Benefits Pharmacy Benefits Physical Therapy Chiropractic Other (Medical) Rehabilitation / Vocational (excluding all of the above) Late Payment Penalties Assessed Attorney's Fees Burial TOTAL LOST TIME PAYMENTS TO DATE Totals D. Recovery code: Remarks for Subrogation for Overpayment for SITF Other E. I certify that the total payments are as correct as the available information indicates. Signature Date Type or Print Name Address E-mail City State Zip Code Phone Number and Ext Insurer/Self Insurer Name Claims Office Name -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-4 REVISION . 07/2011 4 CASE PROGRESS REPORT American LegalNet, Inc. www.FormsWorkFlow.com