Request To Amend Information On A Form WC-14 {WC-14a}

WC-14a REQUEST TO CHANGE INFORMATION ON A PREVIOUSLY FILED FORM WC-14 GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST TO CHANGE INFORMATION ON A PREVIOUSLY FILED FORM WC-14 Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. CLAIM INFORMATION Birthdate County of Injury Address Employee E-mail City State Zip Code Name EMPLOYER Address INSURER/ SELF-INSURER CLAIMS OFFICE Claims Address Name SBWC# (five digit #) Name City State Zip Code City State Zip Code Employer E-mail Claims E-mail ATTORNEY FOR EMPLOYEE/CLAIMANT Address Name GA Bar Number ATTORNEY FOR EMPLOYER/INSURER Address Name GA BAR Number City State Zip Code City State Zip Code Attorney E-mail Attorney E-mail B. INFORMATION TO BE AMENDED The information provided on the Form WC-14 dated _________________________ is amended as follows: Change Date of Injury From: Date of Injury Existing Party Name: 2 Correct a Party's Name Party Name 2 Claims Office 2 Change Date of Injury To: Corrected Party Name: 2 2 Employer Dismiss a Party 2 Insurer Address State Zip Code City 2 Add Hearing Issues C. AFFIRMATION OF FILING PARTY 2 I, (the person whose name appears above), attest and affirm that all information contained herein is true and correct to the best of my knowledge. I understand that knowingly giving false information to obtain or deny workers' compensation benefits subjects me to civil and criminal penalties. D. ENTRY OF APPEARANCE 2 I hereby certify to the existence of a valid fee contract in compliance with Board Rule 108 or a Form WC-1028 in compliance with Board Rule 102. (fee contract or WC-102B has been previously filed or is attached) E. CERTIFICATE OF SERVICE 2 I certify that I have today sent a copy of this form to all parties named above, and have sent this form to the State Board of Workers' Compensation, 270 Peachtree St., NW, Atlanta, Georgia 30303-1299. Signature Date Print Name Phone Number E-mail 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-14a REVISION 02/2016 14a REQUEST TO CHANGE INFORMATION ON A PREVIOUSLY FILED FORM WC-14 American LegalNet, Inc. www.FormsWorkFlow.com