Request For Rehab Conference {WC-R5}

WC-R5 GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST FOR REHAB CONFERENCE Submitted by: Claimant Employer / Insurer M.I. REQUEST FOR REHAB CONFERENCE Supplier SSN or Board Tracking # Date of Injury Board Claim No. Employ ee Last Name Employ ee First Name A. IDENTIFYING INFORMATION Phone Number County of Injury Name EMPLOYEE Address EMPLOYER Address Phone Number City State Zip Code City State Zip Code Employee E-mail Employer E-mail REHAB SUPPLIER Address Name INSURER / SELF-INSURER Phone Number Name CLAIMS OFFICE Address Name Registration Number Phone Number City Supplier E-mail State Zip Code City Claims E-mail State Zip Code SBWC ID# (five digit no) ATTORNEY FOR EMPLOYEE / CLAIMANT Address Name ATTORNEY FOR EMPLOYER / INSURER Phone Number Address Name Phone Number City GA Bar number State Zip Code City GA Bar number State Zip Code Attorney E-mail Attorney E-mail B. ISSUES: C. CERTIFICATE OF SERVICE I certify that I have today sent a copy of this form to all parties name Street N.W., Atlanta, GA 30303-1299 Print Name Here Telephone Number Signature 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 SUBJE CT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-R5 REVISION . 07/2011 R5 REQUEST FOR REHAB CONFERENCE American LegalNet, Inc. www.FormsWorkFlow.com