Wage Documentation {WC-262}

WC-262 WAGE DOCUMENTATION GEORGIA STATE BOARD OF WORKERS' COMPENSATION WAGE DOCUMENTATION OF TEMPORARY PARTIAL DISABILITY PAYMENTS Instructions: Com plete this form w hen the m axim um tem porary partial disability benefits are not being paid and file w ith the Board. When paying w eekly tem porary partial disability incom e benefit s, based upon an actual return to w ork file a Form WC-262 w ith the Board at 13 w eek intervals or w hen such benefits are suspended, w hichever com es first. When filing the Form WC -262 w ith the Board, send a copy to the em ployee and the f represented. Board Claim No. Employ ee Last Name Employ ee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION County of Injury Name EMPLOYEE Address Phone Number EMPLOYER Address Phone Number City State Zip Code City State Zip Code Employee E-mail Employer E-mail INSURER/ SELF-INSURER CLAIMS OFFICE Claims Office E-mail Name SBWC ID# (five digit no.) Phone Number Name Address City State Zip Code B. TEMPORARY PARTIAL DISABILITY BENEFITS START DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 TOTALS END DATE AVERAGE TOTAL GROSS WEEKLY WAGE EARNINGS PAYMENT DIFFERENCE (W eekly W age Gross Earnings) Difference x /3 Not to exceed maximum stated in !34-9-262 2 C. CERTIFICATION I hereby certify that to the best of my know ledge the total payments listed are correct as the available information indicates. Print Name E-mail Date IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE B COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov 34-9-18 AND 34-9-19). 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. WC-262 REVISION . 07/2011 262 WAGE DOCUMENTATION American LegalNet, Inc. www.FormsWorkFlow.com