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STATE BOARD OF WORKERS' COMPENSATION 
 
Guidelines On Completion Of Basic Claims Processing Forms 
- Introduction - 
This handbook provides simple step-by-step instructions on the completion of basic claims processing forms relative to benefit payments as mandated by the State Board of Workers' Compensation. It is primarily intended as a handy reference for insurers, self-insurers and third party administrators. 
Please contact the Training Section of the State Board of Workers' Compensation at (404) 656-3697 for information on additional resources on the Georgia Workers' Compensation System. 
 
 Enter the return to work date when the employee has actually returned to work at the time of filing. 
Type or print the name of the insurer or self-insurer representative completing the form. 
Sign the form and enter the date and telephone number. 
 
FORM WC-1 SECTION C 
 
When the right to income benefits or other compensation is denied or disputed, in whole or part, at the time the Form WC-1 is filed, Section C of the Form WC-1 is completed. 
 
WHO TO WHOM: 
 
The insurer/self-insurer completes Section C and submits the Form WC-1 to the State Board of Workers' Compensation with a copy to the employee and any other persons with a financial interest including, but not limited to, the employer, attorneys, and providers of medical services. 
 
WHEN: 
 
ON OR BEFORE THE TWENTY-FIRST DAY AFTER THE EMPLOYER'S KNOWLEDGE OF THE ALLEGED INJURY. 
 
COMPLETING SECTION C OF THE WC-1 : 
 
Additional space is provided on the reverse side of the Form WC-1 for the information required. 
 
State the specific grounds upon which the right to compensation is controverted, i.e., medical, indemnity or all issues. The employee or potential beneficiary is entitled to know precisely why and to what extent the claim is being controverted. General statements such as "Iiability is not being accepted pending investigation" or "the right is reserved to controvert on further grounds" are not acceptable. 
 
(Rev. 7/01) 
 
Indicate whether the claim is controverted in whole (all issues) or in part (only medical or income benefits). Examples: 
6 
 
 "The injury did not arise out of or in the course of employment." (whole claim) 
"Medical provider is not an authorized doctor." (only medical) 
"Lost time over the waiting period was not authorized by the treating physician and was not related to the injury." (income benefits only) 
Type or print the name of the insurer or selfinsurer representative completing the form. 
Sign the form and enter the date and phone number. 
 
FORM WC-1 WAGE STATEMENT (reverse side) 
 
WHAT: 
 
A form for calculating the average weekly wage of the employee or deceased worker at the time of the injury. 
 
WHO TO WHOM: The employer/self-insurer completes Form WC-1, Section A and the wage statement on the back of the form and submits the form to the insurer or TPA. 
 
WHEN: 
 
IMMEDIATELY UPON KNOWLEDGE OF THE INJURY. 
 
COMPLETING THE FORM: 
 
CALCULATION OF THE AVERAGE WEEKLY WAGE 
 
The employer must use the gross weekly wages of the injured employee for 13 weeks immediately preceding the injury. Weeks prior to this period are disallowed. The injured employee must have worked substantially the whole of the 13 weeks to compute the wage. 
 
(Rev. 7/01) 
 
If the injured employee has not worked substantially the whole of 13 weeks immediately preceding the injury, the employer/insurer must use the gross weekly wages of a similar employee in the same employment who has worked substantially the whole of 13 weeks preceding the injury. The name of the similar employee should be entered in the space provided at the top of the form. 
7 
 
 If the 13-week wage statement of the injured employee or a similar employee cannot reasonably and fairly be applied, the employer's insurer must use the full time weekly wage of the injured employee. 
ADDITIONAL BENEFITS 
Computation of wages shall include, in addition to salary, hourly pay, or tips, the reasonable value of food, housing and other benefits furnished by the employer without charge to the employee which constitute a financial benefit to the employee and are capable of monetary calculation. 
PART-TIME OR TEMPORARY EMPLOYEE 
Unless the contrary appears, it is assumed that a normal workweek is five days, that the normal workday is eight hours, and that the employee's daily wage is one-fifth of the weekly pay. Fractional parts of the day shall be credited proportionately in computing the daily wage. For example, the daily wage of a five and one half-day worker is the weekly wage divided by 5.5. 
CONCURRENT OR SIMILAR EMPLOYMENT 
If the employee has similar concurrent employment, the wages paid by all similar concurrent employers shall be included in calculating the average weekly wage. 
FILING RELATED TO AVERAGE WEEKLY WAGE 
The wage statement should be completed with the initial filing of the Form WC-1 when benefits are commenced. Forms WC-1 or WC-2 must show payment of the maximum weekly benefits under D.C.G.A. 34-9-261 or 34-9-262, as applicable, unless Form WC-6, Wage Statement, or another explanation accompanies the Forms WC-1 or WC-2, or is already on file. 
 
(Rev. 7/01) 
 
8 
 
 SUMMARY OF WORKERS' COMPENSATION PROVISIONS 
 
GEORGIA WORKERS' COMPENSATION ACT AMENDED ON: 
 
7/1/94 
 
7/1/96 
 
7/1/97 
 
TOTAL DISABILITY - CODE 114-404 - O.C.G.A. 34-9-261 
 
Waiting period 
 
7 days 
 
7 days 
 
7 days 
 
Waiting period recoverable after (consecutive from disability date) 
 
21 days 
 
21 days 
 
21 days 
 
Maximum weekly benefit 
 
$275 
 
$300 
 
$325 
 
Percent of average weekly wage (13 weeks prior to accident) 
 
662/3% 
 
662/3% 
 
662/3% 
 
Minimum weekly benefit 
 
$25 
 
$25 
 
$32.50 
 
Maximum weekly duration from date of disability and not date of accident 
 
400 weeks" 
 
400 weeks" 
 
400 weeks" 
 
TEMPORARY PARTIAL DISABILITY CODE 114-405 - O.C.GA 34-9-262 
 
Maximum weekly benefit 
 
$192.50 
 
$192.50 
 
$216.67 
 
Maximum weekly duration from date of injury 
 
350 weeks 
 
350 weeks 
 
350 weeks 
 
Percent of difference in wages before and after injury 
 
662/3% 
 
662/3% 
 
662/3% 
 
Total maximum compensation 
 
$67,375 
 
$67,375 
 
$75,834.50 
 
PERMANENT PARTIAL DISABILITY - CODE 114-406 O.C.G.A. 34-9-263 
 
Maximum weekly benefit 
 
$275 
 
$300 
 
$325 
 
Percent of difference in wages 
 
662/3% 
 
662/3% 
 
662/3% 
 
SPECIFIC MEMBER LOSS OR LOSS OF USE OF: 
 
Thumb 
 
WHki 
 
60 
 
Arm 
 
w.uM 
225 
 
1st (index) finger 
 
40 
 
Foot 
 
135 
 
2nd (middle) finger 
 
35 
 
Leg 
 
225 
 
3rd (ring) finger 
 
30 
 
Eye 
 
150 
 
4th (little) finger 
 
25 
 
Loss of Hearing (one ear) 
 
so Great toe Other toes 
 
30 
 
Total Industrial 75 
 
20 
 
Loss of Hearing (both ears) 
 
Hand 
 
160 
 
Total Industrial 150 
 
Disfigurement 
 
None 
 
Disability/Body as a whole 300 
 
DEATH BENEFITS - CODE 114-413 - O.C.G.A. 34-9-265 
 
Maximum weekly benefit 
 
$275 
 
$300 
 
$325 
 
Maximum duration from injury date 
 
Various 
 
Various 
 
Various 
 
Burialexpel"se 
 
$5000 
 
$5000 
 
$5000 
 
Total maximum benefit 
 
$100,000' 
 
$100,000' 
 
$100,000' 
 
All others 
 
All others 
 
All others 
 
Various 
 
Various 
 
Various 
 
PARTIAL DEPENDENTS 
 
According to the ratio that the contribution bears to wages, 
 
times the amount due a spouse - Maximum. 
 
Various 
 
Various 
 
Various 
 
MEDICAL BENEFITS 
 
Medical Allowance 
 
Unlimited 
 
Unlimited 
 
Unlimited 
 
MISCELLANEOUS 
 
Interest in lump sum payment 
 
7% per annum 
 
7% per annum 
 
7% per annum 
 
Statute of limitations: 
 
For reporting accidents to the Board 
 
1 or 2 yrs see 1 or 2 yrs see 1 or 2 yrs see 
 
For appeal to ThreeMemberBoard For appeal to Superior Court For appeal to Courtof Appeals Number of employees required to come underlaw 
 
OCGA 34-9-B2 
20 days f/award 20 days f/award 30 days f/award 3 
 
OCGA 34-9-B2 
20 days f/award 20 days f/award 30 days f/award 3 
 
OCGA 34-9-B2 
20 days f/award 20 days flaward 30 days f/award 3 
 
7/1/99 
7 days 21 days $350 662/3% $35 400 weeks" $233.33 350 weeks 662/3% $81,665.50 $350 662/3% 
$350 Various $7500 $100,000' All others Various 
Various 
Unlimited 
7% per annum 
1 or 2 yrs see 
OCGA 34-9-B2 
20 days f/award 20 days f/award 30 days f/award 3 
 
7/1100 
7 days 21 days $375 662/3% $37.50 400 weeks" $250 350 weeks 662/3% $87,500 $375 662/3% 
$375 Various $7500 $125,000' All others Various 
Various 
Unlimited 
7% per annum 
1 or 2 yrs see 
OCGA 34-9-B2 
20 days f/award 20 days f/award 30 days f/award 3 
 
'Survivingspouseonly afterone year 
 
"Except for catastrophic injureswhich are unlimited 
 
7/1101 
7 days 21 days $400 662/3% $40 400 weeks" $268 350 weeks 662/3% $93,800 $400 662/3% 
$400 Various $7500 $125,000' All others Various 
Various 
Unlimited 
7% per annum 
1 or 2 yrs see 
OCGA 34-9-B2 
20 days f/award 20 days f/award 30 days f/award 3 
 
 A. Employer 
 
GEORGIA STATE BOARD OF WORKERS' COMPENSATION 
 
EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE 
 
IEmployer Phone No. 
 
Insurer/Self Insurer Name 
 
Address City 
 
State/Zip 
 
Employer FEIN 
INature of Business (Mfg.Trade. Transp . Etc.) 
 
Employer Location Address (If Different) 
 
City 
 
Place of Accident or Exposure (Address or Location) 
 
Occupation 
 
Statc/Zip 
 
OSHA File No. Insurer FIle No. 
TPAlCiaims Office 
 
TPA FEIN 
 
Address 
 
City 
 
State/Zip 
 
TPAlClaims Office Phone No. 
 
Employee Name (Last) (First) (Middle) 
 
Date of Birth 
 
County of Injury 
 
Address 
 
Date oflnjury 
 
Employee Social Security Number 
 
City Male 
 
Female 
 
I State/Zip Employee's Home Ph. # 
 
Time of Injury 
 
I Time Workday Began 
 
Number of Dependents Including Spouse Date Employer Notified 
 
DO NOT WRITE IN THIS COLUMN 
Insurer No. 
 
0 
 
0 
 
Date Hired 
 
Hours Worked Per Day ( ) Per Week ( ) 
 
I I amI ) 
Did Employee Work the Next Day? 
 
pm( ) First Date Employee Failed 
 
Did Employee Receive Full 
 
to Work a Full Day 
 
Pay for Date of Injury? 
 
Io Yes Number of Days Worked Per 
 
IONo List Normally Scheduled Off Days 
 
I OYcs 
 
ONo 
 
Wage Rate at Time of Injury or Disease 
 
I Hour ( ) Day( ) 
 
I Week ( 
 
) 
 
I 
 
I Week( ) Mo.( ) 
 
SIC Date of Birth Sex 
 
COMPLETE WAGE STATEMENT ON REVERSE: If employee is paid hourly. on commission or piecework basis. enter average weekly amount 
 
If board, lodging. or other advantages were furnished. enter average weekly amount 
 
County oflnjury 
 
s 
Did Injuryflliness Exposure Occur on Employer's Premises? 
 
YesO 
 
NoO 
 
$ Type of lnjury/Illncss 
 
I Part of Body Affected 
 
Employer Aware Nature 
 
How Injury or Illness!Abnormal Health Condition Occurred. 
 
If Returned to Work. Give Date 
 
IReturned at What Wage 
 
Ill'Fatal: Give Date of Death 
 
Body Part 
 
. per Week 
 
Cause 
 
Treating Physician (Name and Address) 
 
Initial Treatment 
 
Hospital (Name & Address) 
 
o No Treatment o Minor: By Employer o Minor: ClinielHospital o Emergency Care o Hospitalized> 24 hrs. 
 
M.O. Controvert D. First 
 
Report Prepared By (Print or Type) 
 
I I MCO Yes 0 NoO 
 
Position 
 
Telephone Number 
 
IDate of Report 
 
EMPLOYER'S FAILURE TO SUBMIT THIS REPORT TO INSURER IMMEDIATELY MA Y RESULT IN PE:'ol ALTY 
 
B. 
 
FOR USE BY INSURER/SELF-INSURER 
 
Average weekly wage: $ 
 
Weekly benefit: $ 
 
Date of disability: 
 
Date of first payment: 
 
Compensation paid: $ 
 
Penalty paid: $ 
 
Previously Medical Only Yes 0 No 0 
 
BENEFITS ARE PAYABLE FROM 
 
o o Total/temporary total disability 
 
Temporary partial disability 
 
FOR: 
o Permanent partial disability of - - - % to 
 
Part of Body 
 
- - for 
 
weeks 
 
UNTIL 
 
WHEN THE EMPLOYEE ACTIJALL Y RETIJRNED TO WORK. ALL OTHER SUSPENSIONS REQUIRE THE 
 
FILING OF FORM WC2 WITH THE STATE BOARD OF WORKERS' COMPENSATION AND THE EMPLOYEE. 
 
By 
 
(Insurer/Self Insurer: Type or Print Name of Person Filing Form and Sign) 
 
(Date) 
 
(Phone) 
 
C. 
 
NOTICE TO CONTROVERT PAYMENT OF COMPENSATION (over for additional information) 
 
Benefits WIll not be paid because: 
 
(Extension) 
 
By (lnsurcr/Sclflnsurer: Type or Print Name of Person Filing Fonn and Sign) 
 
(Date) 
 
(Phone) 
 
(Extension) 
 
Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject 10 penalties of up 10 $10.000.00 per violation (O.CG.A. 34-9-1 Mund 34-9-I<I). 
 
FORM WC-1 
 
REv. DATE 7/2001 
 
1 
 
EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE 
 
 FORM WC-2 NOTICE OF PAYMENT OR SUSPENSION OF BENEFITS 
 
WHAT: 
 
Form WC-2 is the form to report the commencement, suspension, or change in income benefits, classification, or rating of disability. 
 
WHO TO WHOM: 
 
The insurer/self-insurer sends the original to the State Board of Workers' Compensation. A copy of both sides of this form must be given to the employee and his/her attorney when payments are started, adjusted, or stopped. 
 
WHEN: 
 
A. SUSPENSION OF INCOME BENEFITS 
 
1. Unilateral Suspension by Insurer/Self-Insurer 
 
The first use of Form WC-2 is to suspend the weekly benefit payment when a change in disability status occurs after Form WC-1 has been properly filed with the Board. The form is used to notify the employee and the Board of suspension of income benefits. Form WC-2 is the proper form to report any change in income benefits, classification, or rating of disability. Form WC-3, Notice to Controvert, is intended to deny liability in whole or in part after Form WC-1 has been filed with the Board, and serves the same purpose as Section C of Form WC-1 . 
 
(Rev. 7/01) 
 
For suspension of income benefits, the insurer/self-insurer files Form WC-2 with the Board, and where needed, Form WC-3 or other documents as stated below, and furnishes a copy to the employee when: 
a. The employee returns to work for the same or 
another employer at a wage equal to or exceeding the average weekly wage at the time of the disabling injury. 
b. The employee is deemed able to return to work 
without limitation. The insurer/self-insurer must attach supporting medical information from the authorized treating physician to Form WC-2 filed with the Board. The insurer/self-insurer must give the employee ten days advance notice of the suspension of income benefits. Unless there is compelling evidence to the contrary, the date stamped by the Board as its date of receipt is 
10 
 
 (Rev. 7/01) 
 
deemed to be the date the employee received notice. 
 
c. The employee is released to return to work with 
restrictions and the employee refuses to attempt to perform a suitable job when the requirements of Board Rule 240 are met. 
 
d. The employee dies. The insurer/self-insurer must 
furnish a copy of the Form WC-2 to the representative of the estate of the deceased employee, if known, and attach a copy of the death certificate, if available. If the insurer/self-insurer contend that the death is unrelated to the injury, a Form WC-3 should accompany the Form WC-2. 
 
e. If within 60 days after the due date of the first 
payment of income benefits (which is 21 days after the employer's notice or knowledge of a lost time disabling injury or disease), the insurer/self-insurer determine to controvert the payment of income benefits for any reason, a Form WC-3 must be filed with the Form WC-2. The insurer/self-insurer must furnish a copy of the Form WC-3 to all persons having a financial interest including, but not limited to, the employer, attorneys, and providers of medical services. To meet the 60-day deadline the documents must be filed with the Board, as shown by the Board's date stamp, within 60 days after the due date of the first payment of income benefits. 
 
f. 
 
If more than 60 days after the due date of the first 
 
payment of income benefits (which is 21 days after 
 
the employer's notice of a lost time disabling injury 
 
or disease), the insurer/self-insurer determine to 
 
controvert on the basis of newly discovered 
 
evidence, Forms WC-3 and WC-2 must be filed 
 
with the Board. a.C.G.A.  34-9-221 requires that 
 
the insurer/self-insurer give the employee 10 days 
 
advance notice of the suspension of income 
 
benefits. The insurer must furnish a copy of Form 
 
WC-3 to all persons having a financial interest 
 
including, but not limited to, the employer, 
 
attorneys, and providers of medical services. 
 
11 
 
 2. Board Order or Award to Suspend 
 
Unless otherwise specified, a Form WC-2 is not used to suspend benefits which are being suspended pursuant to a Board order or award. When an Administrative Law Judge or the Board issues an order or award suspending benefits, the order or award, is mailed to the address of record of all interested parties and provides authority and notice of the suspension. The basis for a Board ordered suspension of income benefits may include any of the following: 
 
a. The refusal of an employee to accept available work suitable to the employee's capacity to work. This most commonly arises when the authorized treating physician limits the employee to light work, and the employer undertakes to provide suitable light work. Board Rule 240 sets forth the procedures to be followed to effectuate the suspension of income benefits. 
 
b. The refusal of an employee to submit to treatment. O.C.G.A 34-9-200 and 200.1 specify treatment as medical, surgical, hospital care, and vocational rehabilitation, or other treatment provided by law. Board Rules 200(d) and 200.1 (h) permit suspension of income benefits only by order of the Board. 
 
c. The refusal of an employee to submit to a medical examination. Board Rule 202(c) permits suspension of income benefits only by order of the Board. 
 
B. CHANGING BENEFITS FROM TEMPORARY TOTAL TO TEMPORARY PARTIAL 
 
(Rev. 7/01) 
 
When the authorized treating physician has released the employee to return to work with restrictions or limitations as required by O.C.G.A. 34-9-104(a) and the injury is not catastrophic, the insurer/self-insurer must complete Form WC-104. Form WC-1 04 must be received by the employee or by counsel for the employee within 60 days of the release to return to restricted work by the authorized treating physician. The insurer/self-insurer shall file a copy of the completed Form WC-104 with the Board. If the employee has not returned to work within 52 consecutive weeks or 78 aggregate weeks from the date the authorized treating physician released the employee to return to restricted work, the insurer/self-insurer is 
12 
 
 C. 1. 
(Rev. 7/01) 
 
authorized to file a Form WC-2 to change weekly disability benefits from temporary total to temporary partial disability benefits. A copy of the authorized treating physician's report stating the employee's ability to return to work with restrictions or limitations must be attached to the Form WC-2 filed with the Board and Section B.5 on Form WC-2 must specify that the employee's injury has not been described as catastrophic. 
For the purposes of calculating temporary partial benefits as contemplated by Code Section 34-9-1 04(a), benefits shall be paid as follows. 
1. When an employee is receiving the maximum benefits for temporary total disability, under Code Section 349-261, the employer shall cause to be paid the employee an amount equal to the maximum benefit allowed for temporary partial disability, under Code Section 34-9-262; or 
2. When an employee is receiving less than the maximum allowed for temporary total disability, the employer shall continue to pay the employee the same benefits as provided by Code Section 34-9-261 not to exceed the maximum benefit provided for temporary partial disability, under Code Section 34-9262. 
RECURRING TOTAL AND TEMPORARY PARTIAL DISABILITY 
Where liability is accepted to pay weekly income benefits and a Form WC-1 has been filed, Form WC-2 is used to show the commencement and suspension of benefits. Form WC-2 is used to commence weekly income benefits for recurring disability when: 
The employee ceases to work for the same or another employer because of the work-related injury, which constitutes a change in condition and not a new accident. An economic loss of wages due to the work-related injury must occur, and this economic loss ordinarily takes place when there is a gradual deterioration of physical condition resulting from the injury, which mayor may not be attributable to working conditions subsequent to the injury. 
A frequent area of litigation (particularly if one employer and two insurers are involved or if two employers and two insurers are 
13 
 
 involved) is whether the inability to continue working involves reinstatement of benefits as a change in condition, or whether it is a condition to be treated as a new accident. Consequently, general guidelines only are stated herein, primarily to guide the investigator before seeking legal advice. The questions below will produce facts on which to reach a decision: 
a. Is the disability to work due to a gradual deterioration, but not the result of any specific incident at work? If the answer is affirmative, it is likely that a change in condition has occurred. 
b. Is the disability to work due to an aggravation of injury by conditions while working for the same employer, but not because of any specific incident? If the answer is affirmative, it is likely that a change in condition has occurred. 
c. Is the disability to work due to an aggravation of the injury while working for another employer? Did the new job involve changed work duties, which bear some relationship to the present disability to work? Was there a specific incident while working on the new job which bears some relationship to the disability to work? An affirmative answer to any of these questions is indicative of a new accident instead of a change in condition. 
2. The employee ceases to work for the same or another employer because of medical treatment including, but not limited to, therapy, surgery, hospitalization, or medical examination resulting from the work-related injury. 
 
3. 4. 
(Rev. 7/01) 
 
The employee ceases to work for the same or another employer and is unable to find any suitable work because of his or her impaired condition resulting from the work-related injury. 
The employee, although working for the same or another employer, is unable to earn as much or more than his or her average weekly wage at the time of the disabling injury, subject to all of the following conditions: 
a. The economic partial loss of earnings results from the 
work-related injury. This may be due to limitations imposed by the authorized treating physician involving lifting, movement, number of hours, or due to the lack of suitable work; 
14 
 
 STATE BOARD OF WORKERS' COMPENSATION 
Guidelines On Completion Of Basic Claims Processing Forms 
- Introduction - 
This handbook provides simple step-by-step instructions on the completion of basic claims processing forms relative to benefit payments as mandated by the State Board of Workers' Compensation. It is primarily intended as a handy reference for insurers, self-insurers and third party administrators. 
Please contact the Training Section of the State Board of Workers' Compensation at (4041 656-3697 for information on additional resources on the Georgia Workers' Compensation System. 
 
 b. The economic partial loss of earnings occurs within 350 weeks from the date of injury; and 
c. The economic partial loss of earnings is a temporary situation. This is the most frequently overlooked condition to determine whether an employee is entitled to temporary partial disability benefits based on a partial loss of earnings, or permanent partial disability based on a permanent physical impairment. The partial wage loss is defined in the law as a disability to work partial in character and temporary in quality. Thus, if the partial wage loss is one which is a permanent loss, it does not meet the requisite temporary quality. Whether to treat the loss as temporary or permanent depends upon a careful evaluation of various factors, including: 
(1) Whether the impairment has reached maximum improvement and whether it temporarily or permanently affects earnings ability. 
(2) Whether normal seniority job promotions, vocational rehabilitation training, experience or other variables will cause the employee in the future to increase earnings to the level of the average weekly wage at the time of injury. 
 
D. 
1. 
(Rev. 7/01) 
 
PERMANENT PARTIAL DISABILITY 
 
Entitlement 
 
Form WC-2 is used to commence income benefits for permanent partial disability or to change classification of income benefits to permanent partial disability benefits. The conditions which entitle an employee to permanent partial disability income benefits include all of the following: 
 
a. 
 
Not entitled to income benefits for total disability to 
 
work. 
 
b. 
 
Not entitled to income benefits for temporary partial 
 
disability to work. 
 
c. 
 
A permanent impairment exists attributable to work- 
 
related injury involving the loss of, or the loss of use of a 
 
body member or the whole person as listed in the 
 
15 
 
 schedule in a.C.G.A. 34-9-263 or entitlement for occupational loss of hearing under a.C.G.A. 34-9-264. 
2. Determination of Loss of or Loss of Use of a Body Member. 
The determination of the extent of the loss is made by the authorized treating physician and stated in terms of disability to the particular member injured or the whole person. The disability is not a disability to work, but is a physical disability, perhaps better understood if thought of in terms of an impairment. 
The percentage of loss or status for certain conditions listed in a.C.G.A. 34-9-263 is controlled by law. These are: 
a. Impairment ratings. In all cases arising under this chapter, any percentage of disability or bodily loss ratings shall be based upon Guides to the Evaluation of Permanent Impairment, fifth edition, published by the American Medical Association. 
b. Loss of more than one major member. Loss of both arms, hands, legs, or feet, or any two or more of these members, or the permanent total loss of vision in both eyes shall create a rebuttal presumption of compensable permanent total disability. 
 
COMPLETING THE FORM: 
1. Form WC-2 
Check type of report and provide insurer file number, employee's social security number, and date of injury. Complete the name and address of the employee, and the name, address, and telephone number of the employer and insurer. 
Check whether or not the employer is utilizing a Board Certified Workers' Compensation Managed Care Organization (WC/MCa.) 
 
(Rev. 7/01) 
 
16 
 
 (Rev. 7/01) 
 
2. Form WC-2 the Body of the Form 
a. Part A of Form WC-2 
(1 ) Complete weekly income benefit and average weekly wage. If the weekly income benefit is less than the maximum amount of temporary total disability benefits allowed by law, attach a Form WC-6 to Form WC-2, unless previously filed. 
(2) Show the "date benefits are payable from" as the date of disability. If the waiting period is not payable, show the date as the eighth day of lost time after disability. 
(3) Check the type of disability and provide the permanent partial disability rating if applicable. 
(4) Show the date of the first check as the date the payment is mailed or made to the employee. Timely payments must be mailed from within the State of Georgia by the due date, which is 21 days after the employer's knowledge or notice of lost time disability. Timely payment made from outside the State of Georgia must be mailed no later than three days prior to the due date. 
(5) Show the total amount paid and indicate the percentage and amount of any late payment penalties. 
b. Part B of Form WC-2 
(1) The date of suspension is the date the event occurs which authorizes suspension, except for the 1O-day notice to the employee when it is determined that the employee is able to return to normal duty work, but has not returned to work. 
17 
 
 (2) The reason for suspension of weekly disability should be indicated, and will be one of the following: 
 
B. Benefits will be suspended on _ ' _ ,_ _, because: _1) Employee returned to work on _ ' _ , 
 
, without restrictions from the 
 
authorized treating physician. 
 
_ 2) Employee returned to work on _ ' _ '_ _, with restrictions from the authorized 
 
treating physician, at pre-injury or higher rate of pay. 
 
_ 3) Employee returned to work on _ ' _ '_ _, with restrictions from the authorized 
 
treating physician, at reduced pay of $ 
 
per week, and temporary partial 
 
disability benefits are shown in Part A above. 
 
_ 4) Employee was able to return to work on _ , _ ,_ _, without restrictions from the 
 
authorized treating physician, the employee is being given ten (10) days notice, and 
 
the authorized treating physician's report is attached. (Board Rule 221.) 
 
_ 5) The employee has had a change in condition pursuant to O.e.G.A. 34-9-104(a)(2) 
 
because he or she is not working, did not have a catastrophic injury, has been 
 
determined by the authorized treating physician to be capable of performing work 
 
with limitations or restrictions for the past 52 consecutive or 78 aggregate weeks, and 
 
was sent Form WC-I04 within sixty (60) days of the release. Temporary partial 
 
disability benefits are shown in Part A above. 
 
_ 6) This was not a catastrophic injury and the maximum number of temporary total 
 
disability payments has been paid. 
 
_ 7) The entire permanent partial disability benefit has been paid. 
 
_ 8) The maximum number of temporary partial disability payments has been paid. 
 
_ 9) This claim is being controverted within sixty (60) days of the due date of first 
 
payment, and a Notice to Controvert, Form WC-3, is being filed with the Board, with 
 
a copy sent to the employee. 
 
_10) Other: 
 
_ 
 
By Type or Print and Sign (Date) 
 
_ Phone 
 
(3). Type or print the name of the insurer/self-insurer representative completing the form. Sign the form and enter date and telephone number. 
 
(Rev. 7/01) 
 
18 
 
 GEORGIA STATE BOARD OF WORKERS' COMPENSATION 
NOTICE OF PAYMENT OR SUSPENSION OF BENEFITS 
 
Commence Suspend Amend the WC-l!WC-2 dated as indicated in _ _ Part A Below/_ _ Part B Below 
 
() Employee's Phone No. 
 
Insurer File Number Social Security Number 
 
Employee Name (First) (Middle) (Last) Employee Street Address 
 
City 
 
State 
 
Date of Injury 
MCO DYes NoD Zip 
 
Employer 
 
Insurer 
 
Address 
 
Address 
 
City 
 
State Zip 
 
Phone 
 
City 
 
State Zip Phone 
 
A. Benefits are being paid to this employee at the rate of$ 
 
 per week based on an average weekly wage of 
 
$ 
 
, payable from 
 
II 
 
for: 
 
total/temporary total disability 
 
temporary partial disability 
 
Disability Date 
 
permanent partial disability of _ _% to 
 
to be paid for 
 
weeks 
 
(part of body) 
 
The date of the first check is 
 
, the amount is $ 
 
, and this: 
 
does not include a penalty. 
 
does include a _ _% penalty in the amount of $, 
 
_ 
 
 File Form WC-6, Wage Statement, if weekly benefit is less than maximum. 
 
B. Benefits will be suspended on 
 
, because: 
 
I) Employee returned to work on 
 
I 
 
I 
 
, without restrictions from the authorized treating physician. 
 
2) Employee returned to work on I I 
 
, with restrictions from the authorized treating physician, at pre-injury or 
 
higher rate of pay. 
 
3) Employee returned to work on 
 
, with restrictions from the authorized treating physician, at reduced pay 
 
of $ 
 
per week, and temporary partial disability benefits are shown in Part A above. 
 
4) Employee was able to return to work on ( ( 
 
, without restrictions from the authorized treating physician, the 
 
employee is being given ten (10) days notice, and the authorized treating physician's report is attached. (Board Rule 22\.) 
 
5) The employee has had a change in condition pursuant to O.CG.A. 34-9-I04(a)(2) because he or she is not working, did not 
 
have a catastrophic injury, has been determined by the authorized treating physician to be capable of performing work with 
 
limitations or restrictions for the past 52 consecutive or 78 aggregate weeks, and was sent Form WC-l 04 within sixty (60) 
 
days of the release. Temporary partial disability benefits are shown in Part A above. 
 
6) This was not a catastrophic injury, and the maximum number of temporary total disability payments has been paid. 
 
7) The entire permanent partial disability benefit has been paid. 
 
8) The maximum number of temporary partial disability payments has been paid. 
 
9) This claim is being controverted within sixty (60) days of the due date of first payment, and a Notice to Controvert, Form 
 
WC-3, is being filed with the Board, with a copy sent to the employee. 
 
10) Other: 
 
By 
 
( 
 
) 
 
(Type or Print and Sign) 
 
(Date) 
 
(Phone) 
 
The original of this form must be filed with the State Board of Workers' Compensation. A copy of both sides of this form must be given to the person receiving 
 
benefits whenpayments arc startedand whenpayments are stopped. 
 
Willfully making a false statement for the purpose of obtaining or denymg benefits is a come subject to penalties of up to $10.000,00 per violation (O.CG,A. 34.Q.18 and 34.919) 
 
FORMWC-2 
 
REv, DATE 7/2001 
 
2 
 
NOTICE OF PAYMENT OR SUSPENSION OF BENEFITS 
 
 FORM WC-2a NOTICE OF PAYMENT OR SUSPENSION OF DEATH BENEFITS 
 
WHAT: 
 
Use to commence, amend, and suspend weekly benefits in death cases. 
 
WHO TO WHOM: The insurer/self-insurer sends the original to the State Board of Workers' Compensation. A copy of both sides of this form must be given to person(s) receiving death benefits and his/her attorney. 
 
WHEN: 
 
Submit Form WC-2a when an employee dies, as a result of a work related injury or occupational disease, leaving persons either wholly or partially dependent upon them for support. Also, used to report no dependent payment made to the State Board of Workers' Compensation. 
 
COMPLETING THE FORM: 
 
Check type of report and provide insurer file number, deceased employee's social security number and the date of the injury. Complete the name and addresses of the deceased employee, employer, and insurer. 
Complete Section A to commence death benefits. 
 
Enter employee's weekly benefit amount. 
 
Enter the average weekly wage of the deceased employee. 
 
Enter the date from which death benefits are payable. 
 
Enter the date the first payment of death benefits is made. 
 
Enter the amount of the first payment. 
 
Check whether a penalty payment is included. 
 
Enter the percentage and amount of any penalties paid. 
 
Enter the date of death. 
Complete the name, address, telephone number, date of birth and relationship of all total dependents. 
 
(Rev. 7/01) 
 
If there are no total dependents, partial dependents may receive benefits. 
19 
 
 If there are no dependents in a compensable death case, the insurer/self-insurer must pay the State Board of Workers' Compensation one-half of the benefits which would have been payable to such dependents or $10,000.00, whichever is less. 
Complete Section B to suspend death benefits. State the reason for the suspension. 
Type or print the name of the insurer/self-insurer representative completing the form. 
Sign the form and enter the date and telephone number. 
 
(Rev. 7/01) 
 
20 
 
 GEORGIA STATE BOARD OF WORKERS' COMPENSATION 
NOTICE OF PAYMENT OR SUSPENSION OF DEATH BENEFITS 
 
Commence 
 
Suspend 
 
Insurer File Number 
 
Amend the WC-I/WC-2a dated 
 
--'1 
 
---'- 
 
indicated in __ Part A Below/ __ Part B Below 
 
_ as 
 
Deceased Employee's Social Security Number 
 
Deceased Employee's Name (First) (Middle) (Last) 
 
Deceased Employee's Street Address 
 
City 
 
State 
 
Zip 
 
Date of Injury 
 
Employer 
 
Insurer 
 
Address 
 
Address 
 
City 
 
State 
 
Zip 
 
Phone 
 
City 
 
State Zip Phone 
 
A: Benefits will be paid at the rate of $ 
 
* per week based on an average weekly wage of $ 
 
payable from 
 
. The date of the first check is 
 
, the amount is $ 
 
and this 
 
does not! 
 
does include a 
 
% penalty in the amount of$ 
 
The date of death was 
 
I 
 
I 
 
* File Form WC-6, Wage Statement, if weekly benefit is less than the maximum. 
 
TOTAL DEPENDENTS: (Use additional sheets if required.) 
 
Name 
 
Address/Telenhone Number 
 
Date of Birth 
 
Relationship 
 
PARTIAL DEPENDENTS: (Complete only when there are no total dependents. Use additional sheets if required.) 
 
Date of 
 
Weekly Contribution 
 
Name 
 
Address 
 
Birth 
 
Relationship 
 
From Deceased 
 
B: BENEFITS WILL BE SUSPENDED ON 
 
_ 
 
Reason: 
 
By 
(Type or Print and Sign) 
 
(Date) 
 
(Phone) 
 
The original of this form must be filed with the State Board of Workers' Compensation. A copy of both sides of this form must be given to the person receiving benefits when payments are started and when payments are stopped. 
 
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 (OC.G.A. 34-9-18 and 34-9-19). 
 
FORM WC-2a 
 
REv. DATE 7/2001 
 
2a 
 
NOTICE OF PAYMENT OR SUSPENSION OF DEATH BENEFITS 
 
 FORM WC-3 NOTICE TO CONTROVERT 
 
WHAT: 
 
Form WC-3 is filed by the insurer/self-insurer when the claim for compensation is denied or disputed in whole or part. 
 
WHO TO WHOM: The insurer/self-insurer files the original form with the State Board of Workers' Compensation. A copy of both sides of the Form WC3 must be sent to the employee and any other persons with a financial interest in the claim including, but not limited to, the employer, attorneys and providers of medical services. 
 
WHEN: 
 
When controverting weekly benefits or other compensation after a Form WC-1 has been filed with the Board. For general guidelines see O.C.G.A. 34-9-221, Board Rule 221, and the back of Form WC-3. 
When controverting the claim in whole when weekly benefits are being paid without an award, file within 60 days of the due date of the first payment of compensation along with Form WC-2 suspending benefits. Board Rule 221 (h) (1). 
When controverting the claim based on newly discovered evidence if benefits have continued for more than 60 days from the due date of first payment, file along with Form WC-2 giving 10 days advance notice of the suspension. Board Rule 221 (h) (2). 
When controverting compensability of medical treatment/test, see O.C.G.A. 34-9-200 and Board Rule 205(b) for general guidelines. 
 
COMPLETING THE FORM: 
 
Enter the employee's name, address, phone number and CORRECT SOCIAL SECURITY NUMBER. 
Enter the insurer file number. 
Enter the date of injury. 
Enter employer's company name, address and phone number. 
 
(Rev. 7/01) 
 
21 
 
 Enter the insurer's name, address, and phone number. 
Check 1 or 2 and state the grounds upon which the right to compensation is controverted. 
List any other person(s) with a financial interest in the claim. 
Type or print the name of the insurer/self-insurer representative completing the form. 
Sign the form and enter the date and telephone number. 
 
(Rev. 7/01) 
 
22 
 
 TABLE OF CONTENTS Basic Claims Processing Forms 
 
Form WC-1 
Employer's First Report of Injury or Occupational Disease 
Summary of Workers' Compensation Provisions 
FormWC-2 
Notice of Payment or Suspension of Benefits 
Form WC-2a 
Notice of Payment or Suspension of Death Benefits 
Form WC-3 
Notice to Controvert 
Form WC-4 
Case Progress Report 
Form WC-6 
Wage Statement 
Form WC-26 
Consolidated Yearly Report of Medical Only Cases 
 
p. 1 p. 9 p. 10 p. 19 p. 21 p. 23 p. 27 p. 28 
 
 GEORGIA STATE BOARD OF WORKERS' COMPENSATION 
NOTICE TO CONTROVERT 
 
Insurer File Number 
 
Employee Name (First) (Middle) (Last) 
 
Employee's Phone Number 
 
Social Security Number 
 
Employee Street Address 
 
City 
 
State 
 
Zip 
 
Date of Injury 
 
Employer 
 
Insurer 
 
Address 
 
Address 
 
City 
 
Slate 
 
Zip 
 
Phone 
 
City 
 
Stale 
 
Phone 
 
1. _ This serves as notice, pursuant to a.e.G.A. 34-9-221, that the right to compensation in this claim is 
being controverted on the following specific grounds: (Pending investigation is not a proper ground for controversion.) If only a part of the claim is being controverted, state the specific part of the claim and the reason it is being controverted. 
 
2. _ This is notice, pursuant to a.e.G.A. 34-9-200 and Board Rule 205(b), that the compensability of the following medical treatment/test is being controverted for the following specific reasons. 
 
This is to certify that a copy of this notice has been mailed to the employee and any other person with a financial interest, as follows: 
 
By (Type or Print and Sign) 
 
(Dale) 
 
() 
(Phone) 
 
The original of this form must be filed with the State Board of Workers' Compensation. A copy of both sides of this form must be given to the employee and any other person with a financial interest in the claim including, but not limited to the employer, medical care provider(s) and attorneyts), 
 
Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties of up 10 $10.00000 per violation IO.e.GA. 34-9-1 Mand 34-9-19) 
 
FORMWC-3 
 
REv. DATE 7/2001 
 
3 
 
NOTICE TO CONTROVERT 
 
 FORM WC-4 CASE PROGRESS REPORT 
 
WHAT: 
 
Form WC-4 provides a periodic review of a claim. It is the basis for reporting all costs related to an individual claim. 
 
WHO TO WHOM: The insurer/self-insurer sends the original form to the State Board of Workers' Compensation. 
 
WHEN: 
 
The following filing guidelines apply: (a) Not later than the 90th day of disability; 
 
(b) Within 30 days from last payment for closure; 
 
(c) Upon request of the Board; 
 
(d) Every 12 months from the date of the last filing of a Form WC-4 on all open claims; 
 
(e) To reopen a claim; 
 
(f) With all no-liability settlement documents, and other settlement documents for which a claim will be immediately closed upon approval; 
 
(g) Within 90 days of receipt of an open claim by the new third party administrator. 
 
COMPLETING THE FORM: 
 
Check type of report and provide insurer file number, employee's social security number, and date of injury. Complete the names of the employee and employer, and check whether the employer is utilizing a Board Certified Workers' Compensation Managed Care Organization (WC/MCO.) 
 
1. Enter the date of the first payment made to the employee. 
 
2. Enter the type and amount of income benefits paid at the time report is filed. The appropriate subsections follow: 
 
a. Subsection (a) for temporary total disability income 
payments under O.C.G.A. 34-9-261. 
 
(Rev. 7/01) 
 
23 
 
 b. Subsection (b) for temporary partial disability income payments under a.C.G.A. 34-9-262. 
c. Subsection (c) for permanent partial disability income payments under a.C.G.A. 34-9-263. This includes payment made in a lump sum for permanent partial disability. 
d. Subsection (d) for death income benefits under a.C.G.A. 34-9-265. Includes payment made in a lump sum. Payment made to the State Board of Workers' Compensation in death cases where there are no dependents must be shown in this section. Burial expenses must be shown in Section 4, Subsection 11 . 
e. Subsection (e) for lump sum amounts paid for stipulated settlements and advances. Amounts paid for no liability stipulated settlements should also be included in Subsection (e). 
Reimbursement of income benefits made by the Subsequent Injury Trust Fund MUST be included in amounts shown in Section 2, and omitted in amounts shown in Section 4( 1). The amount of SITF reimbursements should be shown in the remarks section of Form WC-4. 
When salary is paid in lieu of income benefits, the period for which payments should have been made and the amount of income benefits that would have been paid must be shown in Section 2(a) and Section 4( 1). 
Subrogation reimbursement must be included in the amounts reported on Form WC-4, Section 2 (a) through (e) and Section 4 (1) through (11). The recovery of the insurer/self-insurer should be shown in the remarks section of the Form WC-4. 
3. Enter the first disability date which is the first day on which 
the employee originally lost time from work due to the injury or occupational disease. This date should be the same on subsequent reports (Form WC-4) filed. 
4. Section 4, Subsections 1 through 11 must show all payments as of the date the WC-4 is filed, less reimbursements made by the Subsequent Injury Trust Fund. 
 
(Rev. 7/01) 
 
24 
 
 a. Section 4(1), Total Weekly Benefits. The amount shown must be the total of all payments shown in Subsections (a) through (e), Section 2, less reimbursements made by the Subsequent Injury Trust Fund. 
 
b. Section 4(2), Physician. Show all payments made directly to a physician or medical group, not a hospital or hospital clinic. 
 
c. Section 4(3), Hospital. Show all payments made to hospitals. Include emergency room, outpatient care, inpatient care, and other services provided by hospitals. 
 
d. Section 4(4), Pharmacy. Show all payments to pharmacies, including reimbursement for drugs. 
 
e. Section 4(5), Physical Therapy. Show all payments for physical therapy, including education, (not hospital or hospital clinic.) 
 
f. 
 
Section 4(6), Chiropractic. Show all payments to a 
 
doctor of chiropractic medicine or chiropractic clinic. 
 
The cost of medical care does not include any payments made for utilization or bill review. 
 
g. Section 4(7), Other (Specify). Show other related expenses which do not belong in another category. These include travel expenses (meals, lodging, mileage, etc.,) home health care, nursing home care, home modifications, and automobile or van modifications. 
 
h. Section 4(8), Rehabilitation. Show services of 
rehabilitation suppliers and training expenses (supplier fees, tuition, fees, books, supplies, mileage for rehabilitation suppliers, etc.) 
 
i. 
 
Section 4(9), Late payment Penalties. Show payment 
 
of all 15% and 20% late payment penalties provided 
 
for in O.C.G.A. 34-9-221 (e) and (f). 
 
(Rev. 7/01) 
 
25 
 
 j. 
 
Section 4(10), Assessed Attorney's Fees. Show 
 
attorney's fees assessed as a penalty pursuant to 
 
a.C.G.A. 34-9-108(b). Do not show normal 
 
payment of attorney fees which are part of the 
 
employee's benefit or part of a settlement. These 
 
must be shown in Section 2 and Section 4( 1). Do not 
 
show payments to the attorney for the 
 
employer/insurer. 
 
k. Section 4( 11), Burial. Show burial expenses when paid. Maximum is $7,500. 
 
All money entries should be rounded off to the nearest dollar. 
 
Section 5 must be completed when the employee returns to work. 
 
Sections 6 through 11 should be completed if applicable at time of filing. 
 
The amount of subrogation recovery or Subsequent Injury Trust Fund reimbursements (Indemnity and Medical) should be shown in the remarks section of Form WC-4. 
 
Provide name and address of the insurer/self-insurer. If the insurer is part of a group that is using preprinted forms for more than one company, the name of the company insuring the loss must be indicated. If the claim is handled by a third party administrator (TPA) provide the name of the insurer/self-insurer and name and address of the TPA. 
 
Type or print the name of the insurer or self-insurer representative completing the form and place on top of any accompanying forms. Include the phone number of the person authorized to discuss any questions regarding the information contained in Form WC-4. 
 
(Rev. 7/01) 
 
26 
 
 GEORGIA STATE BOARD OF WORKERS' COMPENSATION CASE PROGRESS REPORT 
Type of Report 
 
Initial Supplement 
 
Final Reopened 
 
Insurer File Number 
 
Employee Name (First) (Middle) (Last) 
 
Social Security Number 
 
Employer 
 
Date of Injury 
 
Is Empioyer enro IIed man MCO I. Date of First Payment 3. Disability Date 
 
yesO N0 0 2. Type of Payment (a) Totalffemporary Total 
 
Rate 
 
Weeks 
 
Days 
 
Total Payments 
 
NOTE: Round to Nearest Dollar. (b) Temporary Partial 
 
(c) Permanent Partial 
 
(d) Death 
 
(e) Other (Specify) 
 
4. 
 
Payments 
 
Total Weekly Benefits 
 
Total Lost Time Payments To-Date 
I 
 
Do Not Use This Column 
 
Do Not Use This Column 
 
Physician Benefits 
 
2 
 
Hospital Benefits 
 
3 
 
Pharmacy Benefits 
 
4 
 
Physical Therapy 
 
5 
 
Chiropractic 
 
6 
 
Other (Specify) 
 
7 
 
Rehabilitation (excluding all of the above) 
 
8 
 
Late Payment Penalties 
 
9 
 
Assessed Attorney's Fees 
 
10 
 
Burial 
 
II 
 
TOTALS 
 
5. Date Returned to Work 
 
6. Date Able to Return to Work 
 
7. Return to Work Wage 
 
S.closing Date 
 
Do Not Use This Column 
DCPR 
 
9. If Employee Worked Between Accident Date and Last Date of Disability, Give Dates: 
 
Insurer's No. 
 
10. Date of Final Weekly Payment 
11. If Permanent Injury, State Loss: REMARKS: 
 
Percentage 
 
Part of Body 
 
I certify to the best of my knowledge the total payments are as correct as the available information indicates, 
 
Insurer 
 
By (Type or Print) 
 
Disability LW Days WC Closing ReviewClk. 
(Date) 
 
Address 
 
Phone 
 
City 
 
State 
 
Zip 
 
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.eGA 34-9-18 and 34-9-19). 
 
FORMWC-4 
 
REv. DATE 7/98 
 
4 
 
CASE PROGRESS REPORT 
 
 FORM WC-6 WAGE STATEMENT 
 
WHAT: 
 
Use Form WC-6 to compute the average weekly earnings of the injured worker or a similar employee. 
 
WHO TO WHOM: 
 
The employer completes wage information and sends to the insurer claims office. Insurer/self-insurer submits to the State Board of Workers' Compensation when the weekly benefit is less than the maximum for total disability or temporary partial disability. 
 
WHEN: 
 
Upon knowledge of a disabling work related injury or occupational disease (use back of Form WC-1.) Also used to established wage loss for temporary partial disability when the employee returns to work at reduced earnings. 
 
COMPLETING THE FORM: 
 
Complete identifying information. Enter employee name and address, the name and address of the employer, employee's social security number, the date of injury and the county where the injury occurred. 
 
Write the name of the similar employee in Section B if the injured employee has not worked substantially the whole of 13 weeks. 
 
Enter the number of hours the employee worked per day or week. 
 
Enter the number of days the employee worked per week. 
 
Enter the employee's wage at date of injury. 
 
Enter any wage rate changes. 
 
Complete the schedule showing gross weekly earnings for the 13 weeks immediately preceding the accident. 
 
Include wages earned at any similar concurrent employment during the 13-week period. 
 
Type or print the name of the person completing the form, sign the form, list the date the form was completed and the phone number of the representative completing the form. 
 
(Rev. 7/01) 
 
27 
 
 GEORGIA STATE BOARD OF WORKERS' COMPENSATION 
WAGE STATEMENT 
A. IDENTIFYING INFORMATION 
 
Employee Name Address 
 
Soc. Security No. 
 
Date of Injury 
 
_ 
 
County ofInjury 
 
_ 
 
Employer Name 
 
Address 
 
_ 
 
B. COMPUTATION OF AVERAGE WEEKLY WAGE 
 
If the weekly benefit is less than the maximum, complete the schedule below for thirteen (13) weeks immediately preceding the accident. If 
 
the employee has not been in your employ for the thirteen (13) weeks, complete this schedule showing gross weekly earnings of a similar 
 
employee in the same employment, and write the name of the similar employee here: 
 
Also use to 
 
establish wage loss for temporary partial disability payments. 
 
Hours Worked 
o per day o per week 
 
Number of Days Worked Per Week 
 
Wage at Date of Injury 
 
$ 
 
per On 
 
0 Hour 0 Day 
 
On 
 
Change in Hourly Rate 
 
to $ 
 
per 
 
to $ 
 
per 
 
Week No. 
 
From Date 
 
(Year) Week 
To 
Date 
 
No. of Days Worked 
 
SCHEDULE OF WEEKLY EARNINGS 
 
Cross Amount Paid 
Includin~ 
Overtime or EXln Wo.-k 
 
Meals 
 
Value of Additional Compensation 
 
Lodging 
 
Renl 
 
Tips 
 
I 2 3 4 5 6 7 8 9 10 II 12 13 
 
Total Averaze Weeklv Earninzs REMARKS: 
 
All Other 
I 
 
Total Earnings 
 
By: (Type or Print and Sign) 
 
(Date) 
 
( 
 
) 
 
Phone 
 
Willfully making a false statement for the purpose of obtaining or denying benefits IS a crime subject to penalties of up to S 10,000.00 per violation (O.e.G.A. 34-9-18 and 34-9-19). 
 
FORMWC-6 
 
REV. DATE 712000 
 
6 
 
W AGE STATEMENT 
 
 FORM WC-26 CONSOLIDATED YEARLY REPORT OF MEDICAL ONLY CASES 
 
WHAT: 
 
A MEDICAL ONLY CLAIM is a claim which paid only medical expenses for a work injury that has seven or less days of lost time from work. 
 
WHO TO WHOM: The insurer/self-insurer submits this form to the State Board of Workers' Compensation. 
 
WHEN: 
 
Yearly, on or before the 31 st day of January following the end of each calendar year. 
 
COMPLETING THE FORM: 
 
It is the responsibility of the insurer or self-insurer to consolidate all individual TPA and claims office reports into one report (Form WC-26) and submit yearly to the State Board. The total number of cases and total money reported is for a calendar year January 1st 
to December 3 pt. File annually even if no reportable injuries or 
payments occurred during the reporting year. 
 
Complete the large block with the name of the insurer, selfinsurer or group self-insurer as certified by the State Board of Workers' Compensation. THIS SHOULD NOT BE THE NAME OF A THIRD PARTY ADMINISTRATOR. 
 
Report separately those medical only injuries and payments of employers utilizing a Certified Workers' Compensation Managed Care Organization (WC/MCO). 
 
Enter the total number of non-WC/MCO medical only injuries reported during the calendar year. If no new injuries were reported, enter "0". 
 
Enter the total amount paid for non-WC/MCO medical only claims during the calendar year. If no medical only payments were made, enter "0". 
 
Enter the total number of WC/MCO medical only injuries reported during the calendar year. If no new injuries were reported, enter "0". 
 
(Rev. 7/01) 
 
28 
 
 Enter the total amount paid for WC/MCa medical only claims during the calendar year. If no medical only payments were made, enter "0". 
 
Type or print the name of the insurer/self-insurer representative completing the form, the telephone number, date the report was completed and the reporting year. 
 
Enter the address of the office submitting the form. 
 
NOTE: 
 
DO NOT REPORT ANY MEDICAL ONLY EXPENSES ON FORM WC-4. 
 
(Rev. 7/01) 
 
29 
 
 THE CLAIMS PROCESS! WHO, WHAT, WHEN, AND WHERE 
 
 GEORGIA STATE BOARD OF WORKERS' COMPENSATION 
CONSOLIDATED YEARLY REPORT OF MEDICAL ONLY CASES 
NOTE: INSURERS GIVE COMPANY NAME. SELF-INSURERS AND GROUP SELF-INSURERS USE NAME AS IT APPEARS ON SELF-INSURANCE PERMIT. 
FOR BOARD USE ONLY 
 
NAME OF INSURER, SELF-INSURER, OR GROUP SELF-INSURER AS CERTIFIED BY THE STATE BOARD OF WORKERS' COMPENSATION 
IT IS THE RESPONSIBILITY OF THE INSURER OR SELF-INSURER TO CONSOLIDATE ALL INDIVIDUAL TPA AND CLAIMS OFFICE REPORTS INTO ONE REPORT AND SUBMIT YEARLY TO THE STATE BOARD OF WORKERS' COMPENSATION. THE TOTAL NUMBER OF CASES AND TOTAL MONEY REPORTED IS FOR A CALENDAR YEAR JANUARY 1st TO DECEMBER 31st. FILE ANNUALLY EVEN IF NO REPORTABLE INJURIES OR PAYMENTS OCCURRED DURING THE REPORTING YEAR. 
FOR ALL MEDICAL EXPENSES, EXCEPT EMPLOYERS UTILIZING A WClMCO, PLEASE REPORT THE TOTAL YEARLY MEDICAL EXPENSES BELOW: 
TOTAL NUMBER OF MEDICAL ONLY INJURIES THIS PERIOD. 
 
TOTAL AMOUNT PAID, MEDICAL ONLY THIS PERIOD. 
 
IF AN EMPLOYER IS UTILIZING A CERTIFIED WORKERS' COMPENSATION MANAGED CARE ORGANIZATION (WCIMCO), PLEASE REPORT THE TOTAL YEARLY MEDICAL EXPENSES BELOW: 
TOT AL NUMBER OF MEDICAL ONLY INJURIES THIS PERIOD. 
 
TOTAL AMOUNT PAID, MEDICAL ONLY THIS PERIOD. 
 
I CERTIFY TO THE BEST OF MY KNOWLEDGE THE TOTAL PAYMENTS SHOWN 
 
HAVE NOT BEEN REPORTED AS LOST TIME MEDICAL ON A FORM WC-4. 
 
By (Type or Print Name) 
 
Phone Number 
 
Date 
 
Address of Submitting Office 
 
REPORTING YEAR 
 
File on or before January 31st following each calendar year. 
Willfully making a false statement forthe purpose of obtaining or denying benefits rs a cnme subject to penalties of up to SIO.O(J(J.<Xl per violation (O.CG.A. 34-9-l Xand 34-9-19). 
 
FORM WC-26 
 
REV. DATE 7/2000 
 
26 
 
CONSOLIDATED YEARLY REPORT OF MEDICAL ONLY CASES 
 
 FORM WC-1 EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE 
 
WHAT: 
 
The initial report of an injury sustained by the employee that has or is expected to result in medical services and/or lost time from. employment. 
 
WHO TO WHOM: The employer completes Section A of the form and the wage statement on the back and submits it to its insurer. 
 
WHEN: 
 
IMMEDIATELY UPON KNOWLEDGE OF AN INJURY 
 
COMPLETING SECTION A OF THE WC-1 : 
Enter the name, address, city and zip code of the employer. 
Enter the employer's phone number. 
Enter the insurer/self-insurer name. 
Enter the employer's FEIN number. 
Enter the nature of the employer's business. 
Enter OSHA file number, if applicable. 
Enter the specific insurer file number which identifies the claim. (This number is entered by the insurer.) 
Please note: 
Form WC-1 should show the complete name and address of the insured employer including all names the employer may use for the business. The name and claims address of the individual insurer must be provided. If claims are serviced by a third party administrator (TPA) the insurer's name and the name and address of the TPA must be shown in the box provided. 
(Rev. 7/01) 
 
 (Rev. 7/01) 
 
Example: 
Employer John Doe d/b/a Doe's Auto Repair 123 Main Street Hometown, GA 30303-3030 
Insurer/Self-Insurer Jones Insurance Co. 
TPA/Claims Office Smith Claims Service P.O. Box 9999 Atlanta, GA 30303-9999 
The complete name and address of the self-insured employer must be shown in the employer block, including the name as it appears on the self-insurer permit. The name as it appears on the permit and the complete address of the claims office must be provided in the insurer block. If claims are serviced by a TPA, the self-insurer's name and the name and address of the TPA must be shown in the box provided. 
Example: 
Employer Local Services Co.lRegional Conglomerate, Inc. 345 Market Street Hometown, GA 30303-4040 
Insurer/Self-Insurer Name Regional Conglomerate, Inc. 
TPA/Claims Office Smith Claims Service P.O. Box 9999 Atlanta, GA 30303-9999 
Enter TPA FEIN number, if applicable. 
Enter TPA/Claims Office phone number. 
Enter the Employer's location address if different from the address previously shown in the employer address block. 
Enter the address or location where the accident or exposure occurred. 
2 
 
 (Rev. 7/01) 
 
Enter the regular occupation of the injured employee. 
Enter the name and address of the injured employee (last name first.) 
Enter injured employee's date of birth. 
Enter the county where the accident or exposure occurred. 
Enter the date of the injury as reported by the injured employee. 
Enter employee's social security number CORRECTLY PLEASE! 
Enter the employee's home phone number or a number where the employee can be reached. 
Enter the number of the employee's dependents including the spouse. 
Check whether the injured employee is male or female. 
Enter the time that the accident or exposure occurred. 
Enter the time the employee's workday began. 
Enter the date the employee reported the injury to a representative of the employer. 
Enter the date the employee was hired. 
Check whether the employee worked the next day following the accident or exposure. 
Enter the first date the employee failed to work a full day because of the injury or exposure. 
Check whether the employee received full pay for the date of injury. 
Enter the number of employee's regularly scheduled hours PER DAY and PER WEEK. 
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 (Rev. 7/01) 
 
Enter the number of days the employee normally worked per week. 
List the normally scheduled off days (Sat., Sun., etc.) 
Enter the employee's wage rate at the time of injury or disease. (Check hour, day, week, or month.) 
If the employee is paid hourly, on commission or piecework basis, enter average weekly amount. 
Enter the average weekly amount of board, lodging, or other compensation furnished to the employee. 
Check whether the accident or exposure occurred on the employer's premises. 
Enter type of illness or injury. 
Enter part of body affected by the injury. 
Describe how the injury or illness/abnormal health condition occurred. 
Enter the date the employee returned to work following the most recent disability period. 
Enter the wage per week at which the employee returned to work. 
If fatal, enter date of death. 
Enter the name and address of the treating physician. 
Check the degree of initial treatment. 
Check whether or not the employer is utilizing a Board Certified Workers' Compensation Managed Care Organization (WC/MCO.) 
If the employee was treated at a hospital, enter the name and address of the facility. 
Print or type the name of the person preparing the Form WC-1. 
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 Enter the position or job title and telephone number of the person preparing the Form WC-1 . 
Enter the date the Form WC-1 was completed. 
 
FORM WC-1 SECTION B 
 
Section B of Form WC-1 is used to commence weekly benefits and to suspend weekly benefits when the employee has actually returned to work at the time the Form WC-1 is filed with the Board. In all other cases, the insurer should file Form WC-2 to commence or suspend benefits. If the injury results in death, a Form WC-2a must be completed. 
 
WHO TO WHOM: The insurer/self-insurer completes Section B and submits the original to the State Board of Workers' Compensation and a copy to the employee. 
 
WHEN: 
 
WITHIN 21 DAYS OF THE EMPLOYER'S KNOWLEDGE OF DISABILITY. 
 
COMPLETING SECTION B OF THE WC-1 : 
 
Enter the employee's average weekly wage. 
 
Enter the employee's weekly benefit amount. 
 
Enter the date of the employee's disability. 
 
Enter the date the first payment of benefits is made to the injured employee. 
 
Enter the amount of compensation paid to the employee. 
 
Enter the amount of any penalties paid. 
 
Check whether the claim was previously medical only. 
 
Enter the date from which benefits are payable to the injured employee. 
 
(Rev. 7/01) 
 
Check the type of income benefit being paid: 
 
* 
 
Permanent partial disability payments are computed 
 
from the Summary of Provisions Table included in 
 
this manual on page 9 and also on the back of the 
 
Form WC-2. 
 
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