Georgia
Workers Comp
Last updated: 9/14/2023
Notice Of Change Of TPA Servicing Agent {WC-121}
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Description
WC-121 - NOTICE OF CHANGE OF TPA / SERVICING AGENT. The purpose of this form is to notify the Board of a change in the TPA/Servicing Agent. This form must be completed by the Insurer, Self-Insurer or Group Fund no later than 30 days prior to the effective date of the change and sent to the State Board of Workers’ Compensation, 270 Peachtree Street NW, Atlanta, GA 30303-1299. A TPA / Servicing Agent MUST be licensed by the Office of the Commissioner of Insurance pursuant to O.C.G.A. §33-23-100. www.FormsWorkflow.com
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