Georgia > Workers Comp
Notice Of Representation Of Any Party Other Than Claimant Or Employer By Attorney WC-102B - Georgia
| Notice Of Representation Of Any Party Other Than Claimant Or Employer By Attorney Form. This is a Georgia form and can be used in Workers Comp . |
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WC-102b NOTICE OF REPRESENTATION OF ANY PARTY OTHER THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY GEORGIA STATE BOARD OF WORKERS' COMPENSATION NOTICE OF REPRESENTATION OF ANY PARTY OTHER THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY (This form is not to be filed by an attorney for claimant / employee) 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 Employee E-mail City State Zip Code ATTORNEY FOR EMPLOYEE / CLAIMANT Address Name Name EMPLOYER Address City GA Bar number State Zip Code City Employer E-mail State Zip Code Attorney E-mail INSURER / SELF-INSURER Name Name PARTY AT INTEREST Address Name CLAIMS OFFICE Address SBWC ID # (five digit no.) City Party E-mail State Zip Code City Claims E-mail State Zip Code B. NOTICE This serves notice that Attorney: of the firm: at mailing address: Telephone Number City Fax Number E-mail Address State Zip Code GA Bar Number Is counsel in this case for the following named party / parties: C. CERTIFICATION on, 270 Peachtree Street N.W., Atlanta, GA 30303-1299 Signature E-mail Address Date -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-102b REVISION . 07/2011 102b NOTICE OF REPRESENTATION OF ANY PARTY OTHER THAN A CLAIMANT OR EMPLOYEE BY AN ATTORNEY American LegalNet, Inc. www.FormsWorkFlow.com
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