FORM CHANGES – EFFECTIVE JULY 1, 2023
WC-P1 PANEL OF PHYSICIANS English/Spanish: Changed the format on the form from boxes to lines across the page. Lines for more than six physicians are provided if needed. Additional physicians can still be added on a separate sheet. A check box is added to indicate when a separate sheet is added. Added a line for Insurer Email. Added a couple of lines of instructions for the injured workers. No substantive change was made to this form. The number of physicians required to be on the panel of physicians remains at six.
BILL OF RIGHTS English/Spanish: Updated the TTD benefits maximum to $800 and TPD benefits maximum to $533. Updated the death benefits TTD benefits maximum to $800. Updated widowed spouse maximum amount from $290,000 to $320,000.
WC-2 NOTICE OF PAYMENT OR SUSPENSION OF BENEFITS: Updated the TTD benefits maximum to $800 and TPD benefits maximum to $533 on back of form in section B.
WC-2A NOTICE OF PAYMENT OR SUSPENSION OF DEATH BENEFITS: Updated the TTD benefits maximum to $800 under Death Benefits on second page.
WC-10 Notice of Election or Rejection of Workers’ Compensation Coverage: moved last sentence under Notice of Election or Rejection of Workers’ compensation Coverage to the first sentence. Correct the last sentence in the third paragraph on the second page– If this occurs you may be covered under the contractor’s workers’ compensation policy. Changed Enforcement Division and phone number to Licensure Division at (404) 463-6794 in the last paragraph on second page.
WC-26 Consolidated Yearly Report for Medical Only/Indemnity Cases: Add Language – Income on Indemnity claims to Total Amount of all Temporary total Income Benefits on Indemnity Claims paid this Year. Add word – Income after Temporary Partial. Add word – Income after Permanent Partial.
WC-121 Notice of Change of TPA/Servicing Agent: Section A – added “Claims” in between Corporate and Contact. Back page section A number 5– Added “Corporate Contact person for claim’s questions”. Back page – added language under section B number 4 – “Do not terminate if going to keep servicing legacy claims. Just fill out Section D”.
WC-131 Application for Permit to Write Insurance: Section A add claims in between Corporate and Contact, Add “FEIN” # box. Back page – 4. Add at the end of sentence ‘for claim or compliance questions”.
WC-131a Annual Insurer Update: Section A – added claims in between Corporate and Contact. Back Page Section A – Added at end of sentence “for claim or compliance questions”.
WC-PMT: Section C – added “and the treatment or testing provider” after the authorized medical provider. In Section E added “and the treatment or testing provider.” after the authorized medical provider.