Application For Lump Sum Advance Payment {WC-25}

WC-25 APPLICATION FOR LUMP SUM / ADVANCE PAYMENT GEORGIA STATE BOARD OF WORKERS' COMPENSATION APPLICATION FOR LUMP SUM / ADVANCE PAYMENT 2 APPLICATION 2 OBJECTION When you receive this completed form, you must file any objection with the Board within 15 days of the date on the certificate of service (O.C.G.A. !9-11-6(e)). If no response is received within the 15 day period, the Board will assume that the request is unopposed. Send to the State Board of Workers' Compensation, 270 Peachtree Street, N.W., Atlanta, Georgia 30303-1299 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 City State Zip Code B. APPLICATION OR OBJECTION SELECT ONE OF THE FOLLOWING THREE OPTIONS: 2 2 2 The employer/insurer agrees to this lump sum/advance. Complete sections C, D and F only. No attachments necessary The employee requests an advance and the employer/insurer does not agree to this lump sum/advance request. This is an objection to a lump sum/advance filed by the employee. Complete section C and F and attach documents in support of objection. Complete all sections and attach all applicable documents. C. AGREEMENT 2 The employer/insurer agrees to advance $ Insurer SBWC ID # (five digit no.) Telephone Number , subject to credit, as noted above, including E-mail credit for interest at 5% per annum, unless otherwise agreed to and allowed by law. (sign below if consented to). Signature of Employer/Insurer Title Date D. AFFIDAVIT 2 Weekly income benefits have been paid to the employee for 26 or more weeks. 2 interest per annum The employee would like a lump sum payment of all remaining income benefits. The employee understands that benefits will be commuted at 5% The employee would like an advance payment of a part of remaining income benefits in the amount of the $ __________________. This advance will 2 be repaid by: 2 Credit to be taken when PPD is commenced (an actual or projected PPD rating must be attached) or upon settlement. 2 Reducing the amount of weekly benefits by $ (a current medical report must be attached). The Employee is: The employee has 2 Married 2 Single 2 Divorced 2 Separated dependents. Their names, ages and relationships to the claimant are: The employee needs this payment because: (list the specific bills or purchases for which you need the money.) the employee will use this money to do the following: 2 I state under oath that all of the information is correct on both sides of this document, and that all additional information requested is attached. 2 The employee hereby authorizes their attorney to receive a lump sum payment of $ 2 whichever is less, unless specifically authorized by the Board). The employee's attorney is waiving any claim for attorney's fees on this advance. SSN or Board Tracking # Date of Injury (not to exceed $500.00 or 25% of advance, Signature of Claimant Sworn to and subscribed before me this Notary Public day of (Month) / (Year) . My Commission Expires: (Month) / (Year) 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-25 REVISION 02/2016 25 1 OF 2 APPLICATION FOR LUMP SUM / ADVANCE PAYMENT American LegalNet, Inc. www.FormsWorkFlow.com WC-25 APPLICATION FOR LUMP SUM / ADVANCE PAYMENT GEORGIA STATE BOARD OF WORKERS' COMPENSATION E. STATEMENT OF MONTHLY EXPENSES AND INCOME EXPENSES House Rent (or Mortgage Payment) Groceries Clothing Child Care Expenses Medical and Dental (Not Workers' Comp. Related) School Expenses Utilities (Gas, Electricity, Water, Telephone) List Expenses per month $ $ $ $ $ $ $ Balance Due List all past due amounts $ $ $ $ $ $ $ Loans for Car, Furniture, etc. Date/Loan Name of Creditor $ Date/Loan Name of Creditor Balance Due $ $ $ OTHER EXPENSES TOTAL EXPENSES INCOME Claimant's Workers' Compensation Benefits Social Security Payment of Claimant Other Income of Claimant Income of Spouse Income of Other Family Members Living with Claimant $ $ $ $ $ $ $ TOTAL INCOME $ $ $ $ $ Attach a current medical report (completed within the last 60 days) stating your physical status, extent and duration of disability, and permanent disability rating. Also attach a copy of past due bills, a copy of estimates on any matter for which you are requesting this payment, if applicable, and other relevant documents, or your request will be denied. F. CERTIFICATE OF SERVICE 2 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 and to all parties and counsel in this claim. NOTE: Good faith effort to resolve issues means employer/insurer have had an opportunity to agree to advance before the request was submitted to the Board. This day of (Month) Signature of Claimant or Attorney / (Year) E-mail GA Bar Number 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-25 REVISION 02/2016 25 2 OF 2 APPLICATION FOR LUMP SUM / ADVANCE PAYMENT American LegalNet, Inc. www.FormsWorkFlow.com