Request For Change Of Address

WC-CHANGE OF ADDRESS GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST FOR CHANGE OF ADDRESS eeds to be filed once as this a claim. Instructions: This form is to be used only to change certain addresses of record. For employees, this form only changes the A. EMPLOYEE CHANGE OF ADDRESS Board Claim Number Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury Old Phone Number New Phone Number Old Address New Address City Old E-mail Address State Zip Code City New E-mail Address State Zip Code B. ALL OTHER PARTY ADDRESS CHANGES EMPLOYER Old Phone Number Name FEIN New Phone Number Old Address New Address City Old E-mail Address State Zip Code City New E-mail Address State Zip Code ATTORNEY Old Phone Number For Employ ee For Employ er Other Name GA Bar number New Phone Number Old Address New Address City Old E-mail Address State Zip Code City New E-mail Address State Zip Code PARTY AT INTEREST Old Phone Number Name New Phone Number Old Address New Address City Old E-mail Address State Zip Code City New E-mail Address State Zip Code C. CERTIFICATE OF SERVICE I certify that I have today sent a copy of this form to all of the parties and have sent this form to the State Board of Work Compensation, 270 Peachtree Street, NW, Atlanta, GA 30303-1299 Print Name Here Signature Date Phone Number E-mail IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF W ORKERS 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). REVISION . 07/2011 WC-CHANGE OF ADDRESS American LegalNet, Inc. www.FormsWorkFlow.com