Georgia > Workers Comp
Request To Amend Information On A Form WC-14 WC-14a - Georgia
| Request To Amend Information On A Form WC-14 Form. This is a Georgia form and can be used in Workers Comp . |
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WC-14a REQUEST TO CHANGE INFORMATION ON A PREVIOUSLY FILED FORM WC-14 GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST TO CHANGE EMPLOYEE/CLAIMANT INFORMATION ON A PREVIOUSLY FILED FORM WC-14 Instructions: The purpose of this form is to change mistakes concerning certain information (Employee Name, SSN or Board Tracking #, Date of Injury, or County of Injury only) on a previously filed Form WC-14. This form shall not be used to change an address of record, add additional parties, or additional dates of injury. Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. CHANGED INFORMATION The information provided on the Form WC-14 dated Change From Employee Name is amended as follows: Change To SSN or Board Tracking # Date of Injury County of Injury Reasons for change(s) above: B. CERTIFICATION I certify that I have today sent a copy of this form to all parties in this claim and to the State Board of Workers' Compensation, 270 Peachtree Street, NW, Atlanta, Georgia 30303-1299 Print name here Address Signature City State Zip Code E-mail GA Bar number Phone Number Date 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-14a REVISION . 07/2011 14a REQUEST TO CHANGE INFORMATION ON A PREVIOUSLY FILED FORM WC-14 American LegalNet, Inc. www.FormsWorkFlow.com
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