Georgia > Workers Comp
Permit To Write Insurance Update WC-131A - Georgia
| Permit To Write Insurance Update Form. This is a Georgia form and can be used in Workers Comp . |
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WC-131a ANNUAL INSURER UPDATE GEORGIA STATE BOARD OF WORKERS' COMPENSATION ANNUAL INSURER UPDATE In conformity with Title 34, Section 34-9-131 of the Code of Georgia, it is hereby represented that the undersigned applicant has heretofore been licensed by ance, and has complied with the provisions of the laws of the State of Georgia regulating insurance companies, under the provisions of the Georgia Workers Compensation Act. Send this form, accompanied by current GA Certificate of Authority, to the State Boar -1299. SECTION A. CORPORATE / ADMINISTRATIVE OFFICE (Licensure, Permit, Assessment Contact) Name of Carrier (As it appears on permit) SBWC ID # FEIN # Address City State Zip Code Contact Person Title Toll Free Phone Number and Ext Primary E-mail Address for Licensure/Assessment Secondary E-mail Address for Licensure/Assessment SECTION B. CLAIMS HANDLING (Please state where Primary on Claims are Handled) The above-named insurer / self-insurer / group fund has obtained the services of the following individual, firm, or company, as its servicing agent for Name of TPA / Servicing Agent FEIN # Address City State Zip Code Contact Person Title Toll Free Telephone Number and Ext Primary E-mail Address for Claims Handling Secondary E-mail Address for Claims Handling Number of Adjusters Handling Claims Number of Locations/Offices Handling GA Claims SECTION C. (If Section A and B are locations outside the State of Georgia, Section C must be completed) GEORGIA AGENT MUST be located Georgia and MUST be able to execute payment/have check writing authority. Company Contact Person Telephone Number and Ext Mailing Address City State Zip Code E-mail Address Toll Free Telephone Number and Ext Compensation Act as embodied in title 34 of the Code of Georgia of 1982, as amended. Signed This Day of Name of Company and Person Completing this application , 20___. AT 404-651-7839 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-131a REVISION . 07/2011 131a ANNUAL INSURER UPDATE American LegalNet, Inc. www.FormsWorkFlow.com
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