Board Forms Related Links
Board Forms
Effective 7/1/2023, the Board forms are available in a fillable format for printing or downloading a copy to your storage media. If you have any questions, please call the Board’s Call Center at 404-656-3818 or 1-800-533-0682.
Beginning October 1, 2023, outdated forms will be returned.
| FORM |
REVISION |
TITLE |
|---|---|---|
|
WC-BOR |
2023 | Bill of Rights |
|
WC-BOR-Sp |
2023 | Bill of Rights - Spanish (Declaración de Derechos en Español) |
|
WC-P1 |
2023 | Panel of Physicians |
|
WC-P1Sp |
2023 | Panel of Physicians - Spanish (Panel de Medicas en Español) |
|
WC-P3 |
2022 | WC/MCO Panel |
|
WC-P3Sp |
2023 | WC/MCO Panel - Spanish (Panel WC/MCO en Español) |
|
WC-1 |
2021 | Employer's First Report of Injury |
|
WC-2 |
2023 | Notice of Payment or Suspension of Benefits |
|
WC-2a |
2023 | Notice of Payment or Suspension of Death Benefits |
|
WC-3 |
2021 | Notice to Controvert |
|
WC-4 |
2021 | Case Progress Report |
|
WC-6 |
2018 | Wage Statement |
| WC-7 | Application for Self Insurance (Packet available through Licensure & Self-Insurance Division (404) 651-7839 |
|
|
WC-10 |
2023 | Notice of Election or Rejection of Workers' Compensation Coverage |
|
WC-11 |
2021 | Standard Coverage Form Group Self-Insurance Fund Members |
|
WC-12 |
2022 | Request for Copy of Board Records |
|
WC-14 |
2022 | Notice of Claim/Request for Hearing/Request for Mediation |
|
WC-14a |
2022 | Request to Change Information on a Previously Filed Form WC-14 |
|
WC-15 |
2018 | Attorney Certification for No-Liability Stipulations |
|
WC-20a |
2018 | Medical Report |
|
WC-25 |
2022 | Application/Objection for Lump Sum/Advance Payment |
|
WC-26 |
2023 | Consolidated Yearly Report of Medical Only Cases/Indemnity Cases |
|
WC-100 |
2018 | Request for Settlement Mediation |
|
WC-102 |
2021 | Request for Documents to Parties |
|
WC-102b |
2018 | Notice of Representation |
|
WC-102c |
2018 | Attorney Leave of Absence |
|
WC-102d |
2021 | Motion/Objection to Motion |
|
WC-104 |
2018 | Notice to Employee of Medical Release to Return to Work with Restrictions or Limitations |
|
WC-108a |
2018 | Attorney Fee Approval |
|
WC-108b |
2021 | Attorney Withdrawal/Lien |
|
WC-121 |
2023 | Notice of Change of TPA/Servicing Agent |
|
WC-131 |
2023 | Application for Permit to Write Insurance |
|
WC-131a |
2023 | Annual Insurer Update |
|
WC-200a |
2021 | Change of Physician/Additional Treatment by Consent |
|
WC-200b |
2021 | Request/Objection for Change of Physician/Additional Treatment |
|
WC-205 |
2021 | Request for Authorization of Treatment or Testing by Authorized Medical Provider |
|
WC-206 |
2021 | Request to Become a Party at Interest |
|
WC-207 |
2021 | Authorization and Consent to Release Information |
| WC-208 | Application for Certification of WC/MCO (Packet available through Managed Care & Rehabilitation Division (404) 656-0849) |
|
|
WC-226a |
2018 | Petition for Appointment of Temporary Conservator of Minor(s) |
|
WC-226b |
2021 | Petition for Appointment of Temporary Conservator of Legally Incapacitated Adult |
|
WC-240 |
2021 | Notice to Employee of Offer of Suitable Employment |
|
WC-240a |
2018 | Job Analysis |
|
WC-243 |
2021 | Credit |
|
WC-244 |
2021 | Request to Become a Party at Interest |
|
WC-262 |
2021 | Wage Documentation of Temporary Partial Disability Payments |
|
WC-PMT |
2023 | Petition to Show Cause Regarding Medical Treatment/Testing Recommended by Authorized Medical Provider |
|
WC-PMT(b) |
2021 | Petition to Show Cause Regarding Medical Treatment/Employee’s Failure to Attend Medical Appointment with an Authorized Treating Physician |
|
WC-R1 |
2022 | Request for Rehabilitation |
|
WC-R1CATEE |
2022 | Employee's Request for Catastrophic Designation |
|
WC-R2 |
2022 | Rehabilitation Transmittal Form |
|
WC-R2a |
2022 | Individualized Rehabilitation Plan |
|
WC-R3 |
2022 | Request for Rehabilitation Closure |
|
WC-R5 |
2021 | Request for Rehab Conference |
|
Rehab |
2018 | Rehab Objection |
|
Rehab |
2021 | Catastrophic Rehab Release |
|
Change |
2021 | Request for Change of Address |
|
Change |
2022 | Request to Change Information |
|
Subpoena |
2021 | Subpoena |