Georgia > Workers Comp
Notice Of Payment Or Suspension Of Benefits WC-2 - Georgia
| Notice Of Payment Or Suspension Of Benefits Form. This is a Georgia form and can be used in Workers Comp . |
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WC-2 NOTICE OF PAYMENT / SUSPENSION OF BENEFITS GEORGIA STATE BOARD OF WORKERS' COMPENSATION NOTICE OF PAYMENT OR SUSPENSION OF BENEFITS INITIAL PAYMENT Board Claim No. RE-COMMENCE Employee Last Name SUSPEND Employee First Name AMENDMENT: M.I. WC-1 Dated WC-2 Dated Date of Injury SSN or Board Tracking # A. IDENTIFYING INFORMATION EMPLOYEE Address Employee E-mail EMPLOYER Address City Name State Zip Code City State Name Name Claims Office E-mail Zip Code Employer E-mail Address City Phone Number State Zip Code INSURER/ SELF-INSURER CLAIMS OFFICE Insurer/Self-Insurer File # SBWC ID# (five digit no.) B. INCOME BENEFITS Benefits are being paid to this employee at the rate of $ payable from Temporary Total Disability Temporary Partial Disability Permanent Partial Disability of Date of Disability The date of the first check is, Does not include a penalty Does include a % to (Part of Body) to be paid for weeks (medical report attached). *per week based on an average weekly wage of $ / / for: / / , the amount is $ , or date salary was paid / / and this: % penalty in the amount of $ . *File Form WC-6, Wage Statement, if weekly benefit is less than maximum. C. SUSPENSION OF BENEFITS Benefits will be suspended on 1.) Employee returned to work on 2.) Employee returned to work on / / / / / / because: without restrictions from the authorized treating physician. 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 B above. without restrictions from the authorized treating physician, the employee is being (i)(4)). 5.) The employee had undergone a change in condition pursuant to O.C.G.A. 34-9-104(a) (2) because the employee 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-104 within sixty days of the release. Temporary partial disability benefits are shown above in part B above. A copy of the Form WC-104 is attached. 6.) The employee has been offered suitable employment pursuant to O.C.G.A. 34-9-240 and has unjustifiably refused to attempt to perform the job. Form WC-240 was sent at least ten days before the employee was required to report for work. A copy of the Form WC-240 is attached. 7.) This was not a catastrophic injury and the maximum number of temporary total disability payments has been paid. 8.) The entire permanent partial disability benefit has been paid. 9.) The maximum of temporary partial disability payments has been paid. 10.) This claim is being controverted within sixty days of the due date of first payment. File the Form WC-3 simultaneously and send a copy to the employee. 11.) Other: Insurer/Self-Insurer Type or Print Name Signature Date 4.) Employee was able to return to work on / / Phone Number and ext. E-mail e claimant(s) and all counsel of record. -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-2 REVISION . 07/2011 2 1 OF 2 NOTICE OF PAYMENT / SUSPENSION OF BENEFITS American LegalNet, Inc. www.FormsWorkFlow.com WC-2 NOTICE OF PAYMENT / SUSPENSION OF BENEFITS GEORGIA STATE BOARD OF WORKERS' COMPENSATION A. OUTLINE OF BENEFITS OTHER THAN MEDICAL EXPENSE In addition to paying your medical expenses for an injury at work, the employer will pay you for part of your lost wages if you are disabled from work for more than seven (7) calendar days because of your work-related injury. TEMPORARY TOTAL O.C.G.A. 34-9-261: IF YOU ARE NOT ABLE TO WORK AT ALL because of your injury, your employer/insurer must pay: 2/3 of your average weekly wage with a maximum of $450 per week if your date of accident was on or after July 1, 2005, and a maximum of $500 per week if your date of accident was on or after July 1, 2007. A minimum of $50.00 per week, or your actual weekly wage if less than $50.00 per week. If your accident occurred on or after July 1, 1992, and if your injury is not catastrophic, you are not entitled to this type of benefit for more than 400 weeks. Furthermore, your benefits may be reduced to those allowed by O.C.G.A. 34-9-262 under certain circumstances after you have been released to return to work with limitations or restrictions. TEMPORARY PARTIAL O.C.G.A. 34-9-262: IF YOU MUST WORK FOR LOWER WAGES because of your injury at work, your employer/insurer will pay: 2/3 of your wage loss (the difference between what you make after your injury and what you made before), with a maximum of $300 per week if your date of accident was on or after July 1, 2005, and a maximum of $334 per week if your date of accident was on or after July 1, 2007 for a maximum of 350 weeks from the date of accident. PERMANENT PARTIAL O.C.G.A. 34-9-263: IF YOU LOST A PART OR MEMBER OF YOUR BODY or lose the use of a member (such as arm, finger, eye, etc.), you will first receive benefits described above during disability, and then upon return to work or otherwise becoming ineligible for TTD or TPD benefits, you will receive payment for permanent partial disability for a certain number of weeks, based on the percentage of your loss. Multiply the permanent partial disability (%) by the maximum number of weeks listed below to determine the number of weeks you will receive PPD benefits. For example, for a 15% permanent partial disability to an arm, multiply 15% times 225 weeks. The answer of 33.75 represents the number of weeks you will receive income benefits. Bodily Loss Maximum Weeks Arm .................................................................................... 225 Leg ..................................................................................... 225 Hand .................................................................................. 160 Foot .................................................................................... 135 Thumb .................................................................................. 60 Index Finger ......................................................................... 40 Middle Finger ....................................................
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