Request For Copy Of Board Records {WC-12}

WC-12 REQUEST FOR COPY OF BOARD RECORDS GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST FOR COPY OF BOARD RECORDS A minimum charge of $10.00 will be incurred for 10 copies or less, with a charge of $0.50 for each additional copy. All coverage information is certified with a $10.00 charge for certification. Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. TYPE OF COPIES Current Case Priors Certified Copy Subsequent Address B. REQUEST COVERAGE INFORMATION Employer Name Doing Business At: City State Zip Code C. CERTIFICATION I hereby certify that I have this day sent Compensation, 270 Peachtree Street, NW, Atlanta, GA 30303-1299, this (Day) Day of (Month) / (Year) Name Law Firm or Company Signature Party Attorney for (Please Name) E-mail GA Bar Number Phone and Ext. ADDRESS LABEL In this space type the address to which you want these copies mailed. Invoice Date FOR BOARD USE ONLY Do not write in this space Invoice Number Number of Pages Copied By: Additional Board Claim Numbers Additional Dates of Injury -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-12 REVISION . 07/2011 12 REQUEST FOR COPY OF BOARD RECORDS American LegalNet, Inc. www.FormsWorkFlow.com