GEORGIA STATE BOARD OF WORKERS' COMPENSATION
WC-10 REVISION 5/2013 10 NOTICE OF ELECTION OR REJECTION OF WORKERS' COMPENSATION COVERAGE 1 OF 2 OF WORKERS' COMPENSATION COVERAGE. The use of this form is required under the provisions of: (A) O.C.G.A. §34-9-2.1 of the Workers' Compensation Law if a corporate officer or limited liability
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sbwc.georgia.govCheck only REQUEST one: 2NOTICE OF CLAIM ONLY2 HEARING / NOTICE OF CLAIM 2REQUEST FOR MEDIATION / NOTICE OF CLAIM. Complete a new Form WC-14 to add an additional employer, insurer or to add date of injury. If you need additional space, do not alter this form, but instead attach additional sheets. Must be typed or printed in black ink.
EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL …
sbwc.georgia.govIf Section C is completed, your claim of injury has been denied by the employer/insurer. If you disagree with this denial, you must file a form WC-14, Notice of Claim, within one year of the accident with the State Board of Workers' Compensation, 270 Peachtree Street N.W., Atlanta, Georgia 30303-1299.
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