WC 102b
WC 102b
WC 102b
A. IDENTIFYING INFORMATION
County of Injury Address
EMPLOYEE
Employee E-mail City State Zip Code
ATTORNEY FOR Name Name
EMPLOYEE / EMPLOYER
CLAIMANT
Address Address
City State Zip Code City State Zip Code
GA Bar number Employer E-mail
Attorney E-mail Name
INSURER /
SELF-INSURER
PARTY AT Name Name
INTEREST CLAIMS OFFICE
Address Address SBWC ID # (five digit no.)
City State Zip Code City State Zip Code
Party E-mail Claims E-mail
B. NOTICE
This serves notice that Attorney:
C. CERTIFICATION
I certify that I have today sent a copy of this form to all parties named above and to the State Board of Workers’ Compensation, 270 Peachtree
Street N.W., Atlanta, GA 30303-1299
Signature E-mail Address 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).