Motion-Objection To Motion {WC-102D}

WC-102D MOTION / OBJECTION TO MOTION GEORGIA STATE BOARD OF WORKERS' COMPENSATION MOTION / OBJECTION TO MOTION 0 Motion 0 Objection to Motion When you receive this completed form, you may file a response with the Board within fifteen (15) days of the date of the certificate of service (O.C.G.A. !9-11-6 (e)) All responses must be filed on Form WC-102D. Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION County of Injury Address EMPLOYEE E-mail Address City State Zip Code Name EMPLOYER Address INSURER / SELF-INSURER CLAIMS OFFICE Address Name Name City State Zip Code City State Zip Code Employer E-mail Claims E-mail ATTORNEY FOR EMPLOYEE / CLAIMANT Address Name ATTORNEY FOR EMPLOYER / INSURER Address Name City GA Bar Number State Zip Code City GA Bar Number State Zip Code Attorney E-mail Attorney E-mail B. ACTION REQUESTED 0 1. This MOTION is being requested by The purpose of this motion is to request: 0 Employee 0 Employer/Insurer 0 Other Party (Arguments and documentation in support of this motion are attached.) 0 2. This OBJECTION is being submitted by The purpose of this objection is to request: 0 Employee 0 Employer/Insurer 0 Other Party (Arguments and documentation in support of this objection are attached.) C. ENTRY OF APPEARANCE 0 I hereby certify to the existence of a valid fee contract in compliance with Board Rule 108 or Form WC 102B filed in compliance of Board Rule 102. (A fee contract or Form WC 102B has been filed previously or is attached). D. CERTIFICATE OF SERVICE 0 I hereby certify that the parties have made a good faith effort to reach agreement on this issue, but have failed to do so to date. I further certify that I have this day sent a copy of this form with supporting documentation to the State Board of Workers' Compensation, 270 Peachtree St., NW, Atlanta, GA 30303-1299 and to all parties and counsel in this claim. Signature Print Name Here Phone Number E-mail Address 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-102D REVISION 07/2014 102D MOTION / OBJECTION TO MOTION American LegalNet, Inc. www.FormsWorkFlow.com