Georgia > Workers Comp
Notice Of Payment Or Suspension Of Death Benefits WC-2a - Georgia
| Notice Of Payment Or Suspension Of Death Benefits Form. This is a Georgia form and can be used in Workers Comp . |
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WC-2a NOTICE OF PAYMENT / SUSPENSION OF DEATH BENEFITS GEORGIA STATE BOARD OF WORKERS' COMPENSATION NOTICE OF PAYMENT OR SUSPENSION OF DEATH BENEFITS COMMENCE Board Claim No. Employee Last Name Employee First Name SUSPEND M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION Name of Claimant / Guardian Address City State Zip Code INSURER / SELF-INSURER CLAIMS OFFICE Address Name Name EMPLOYER Name Address Phone Number Phone Number Insurer/Self-Insurer File # City State Zip Code SBWC ID # (five digit number) City State Zip Code Claims E-mail Employer E-mail B. DEATH BENEFITS 1. Benefits will be paid at the rate of $ Payable from *per week based on an average weekly wage of $ . The date of the first check is , , the amount is $ / / , / / does not / does Include a And this % penalty in the amount of $ *File Form WC-6, Wage Statement, if weekly benefit is less than the maximum . The date of death was 2. Benefits will be suspended on because: C. TOTAL DEPENDENTS (Use additional sheets if required) NAME ADDRESS PHONE NUMBER BIRTHDATE RELATIONSHIP D. PARTIAL DEPENDENTS (Complete only when there are no total dependents. Use additional sheets if required) NAME ADDRESS PHONE NUMBER BIRTHDATE RELATIONSHIP E. NO DEPENDENTS 2 e claimant(s) and all counsel of record. Type or Print Name Signature Date E-mail Phone and Ext IF YOU HAVE QUESTIO -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-2a REVISION . 07/2011 2a 1 OF 2 NOTICE OF PAYMENT / SUSPENSION OF DEATH BENEFITS American LegalNet, Inc. www.FormsWorkFlow.com WC-2a NOTICE OF PAYMENT / SUSPENSION OF DEATH BENEFITS GEORGIA STATE BOARD OF WORKERS' COMPENSATION A. OUTLINE OF BENEFITS DEATH BENEFITS O.C.G.A. 34-9-265: If an EMPLOYEE IS INJURED AT WORK AND DIES AS A RESULT, his or her DEPENDENTS receive: Medical expenses for the deceased's last injury. Up to $7,500 for funeral expenses. 2/3 of the deceased's average weekly wage with a maximum of $450 per week for accidents on or after July 1, 2005, and a maximum of $500 per week for accidents on or after July 1, 2007. A minimum of $50.00 per week, or the actual weekly wage if less than $50.00 per week. If the surviving spouse is or becomes the SOLE DEPENDENT within the first year following the death of the employee, the amount of weekly benefits the spouse alone will be entitled to the maximum allowed at the time of injury. Compensation provided by this code section is PAYABLE ONLY TO DEPENDENTS and ONLY DURING DEPENDENCY. If there is MORE THAN ONE DEPENDENT, weekly benefits will be APPORTIONED AMONG THE DEPENDENTS. DEFINITION OF DEPENDENT O.C.G.A. 34-9-13: The following are some of the persons who may receive benefits: A SURVIVING SPOUSE who had not voluntarily abandoned his/her spouse at the time of the accident resulting in death. Dependency shall terminate upon remarriage or cohabitation in a meretricious relationship. UNMARRIED CHILDREN (including stepchildren, adopted children, and posthumous children) under 18 years of age (under 22 if a full-time student in a post-secondary institution of higher learning) or incapable of self-support. PARTIAL DEPENDENTS - Persons partially dependent are eligible only if there are no total dependents. NO DEPENDENT DEATH CASES Rule 265: The insurer or self-insurer in no-dependency death cases, shall pay to the State Board of Workers' Compensation the amount set forth in Code Section 34-9-265(b). B. RIGHT TO HEARING If your benefits as a dependent have been suspended and you believe that benefits were suspended incorrectly, you should request a hearing by sending Form WC-14 to the State Board of Workers' Compensation at the address below. If you need a Form WC-14, Compensation at the phone numbers listed below or visit the website. STATE BOARD OF WORKERS' COMPENSATION 270 PEACHTREE STREET, N.W., ATLANTA, GEORGIA 30303-1299 In Atlanta: 404-656-3818 or: 1-800-533-0682 http://www.sbwc.georgia.gov IF YOU HAVE QUESTIO -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-2a REVISION . 07/2011 2a 2 OF 2 NOTICE OF PAYMENT / SUSPENSION OF DEATH BENEFITS American LegalNet, Inc. www.FormsWorkFlow.com
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