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The Georgia WC-3 form, officially known as the Notice to Controvert, plays a crucial role in the state's workers' compensation system. It serves primarily to inform the Georgia State Board of Workers' Compensation that a party, typically the employer or insurer, disputes the right of a claimant to receive benefits following a workplace injury. This form requires detailed identifying information, including the claimant's name, date of injury, and both the employer's and insurer's contact details. In Section B, individuals must specify the grounds for the controversion, whether it be related to the right to compensation itself or the compensability of specific medical treatments. If only part of the claim is being contested, the form allows for a clear delineation of which aspects are in question. Moreover, compliance with the timeline is vital; the form must be submitted within 21 days of the employer's knowledge of the injury. A Certificate of Service section ensures that all relevant parties are notified, including the employee and any legal counsel involved. Therefore, understanding the WC-3 form's requirements and implications is essential for anyone navigating the complexities of workers' compensation claims in Georgia.

Georgia Wc 3 Example

WC-3 NOTICE TO CONTROVERT

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

NOTICE TO CONTROVERT

Board Claim No.

Employee Last Name

Employee First Name

M.I.

Date of Injury

 

 

 

 

A. IDENTIFYING INFORMATION

 

 

 

 

 

EMPLOYEE

 

Mailing Address

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee E-mail Address

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER

 

Name

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

Employer E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURER/

 

Name

 

 

Insurer/Self-Insurer File #

 

 

 

 

 

 

 

 

 

SELF-INSURER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIMS

 

Name

 

 

Claims Office E-mail

 

 

 

 

 

 

 

 

 

 

 

OFFICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SBWC ID

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

B. CONTROVERT TYPES

1. This serves as notice, pursuant to O.C.G.A. §34-9-221, that the right to compensation in this claim is being controverted on the following

 

specific grounds:

 

 

 

2.

This is notice, pursuant to O.C.G.A. §34-9-200 and Board Rule 205(b), that the compensability of the following medical treatment / test is

 

 

being controverted for the following specific reasons:

 

 

 

3.

If only part of the claim is being controverted, state the specific part of the claim and the reason(s) it is being controverted:

 

 

 

 

 

C. CERTIFICATE OF SERVICE

 

 

This is to certify that a copy of both sides of this notice has been sent to the employee / claimant(s), all counsel of record and any other person with

 

a financial interest, as listed below:

 

 

 

 

 

 

 

 

 

 

 

 

 

Type or Print Name

 

Signature

 

Date

 

 

 

 

 

Phone Number

 

E-mail Address

 

 

 

 

This form must be filed with the State Board of Workers' Compensation. A copy of both sides of this form must be given to the employee and any other

person with a financial interest in the claim including, but not limited to the employer, medical care provider(s) and attorney(s).

 

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).

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NOTICE TO CONTROVERT

 

 

 

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WC-3

NOTICE TO CONTROVERT

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

INFORMATION FOR THE INSURER/SELF-INSURER:

Board Rule 61(b)(1): An insurer who receives a Form WC-1 from an employer shall clearly stamp the date of receipt on the form, review Section A, and complete any unanswered questions. The insurer shall complete either Section B or Section C or Section D and, by the 21st day following the employer's knowledge of disability, forward the original to the Board and a copy to the employee.

Board Rule 61(b)(4): previously been filed. 9-221 and Rule 221.

Form WC-3. Notice to Controvert Payment of Compensation. Complete Form WC-3 to controvert when a Form WC-1 has Furnish copies to employee and any other person with a financial interest in the claim. See subsections (d), (h), and (i) of Code §34-

O.C.G.A. §34-9-221(d): If the employer controverts the right of compensation, it shall file with the Board, on or before the twenty-first day after knowledge of the alleged injury or death, a notice in accordance with the form prescribed by the Board, stating that the right of compensation is controverted and stating the name of the claimant, the name of the employer, the date of the alleged injury or death, and the ground upon which the right to compensation is controverted.

Board Rule 221(d): To controvert in whole or in part the right to income benefits or other compensation use Form WC-1 or WC-3. Failure to file the Forms WC-1 or WC-3 before the 21st day after knowledge of the injury or death may subject the employer/insurer to assessment of attorney's fees. See O.C.G.A. §34-9-108(b)(2)(3).

O.C.G.A. §34-9-221(h): When compensation is being paid without an award, the right to compensation shall not be controverted except upon the grounds of change in condition or newly discovered evidence unless a notice to controvert is filed with the Board within 60 days of the due date of first payment of compensation.

Board Rule 221(h)(1): A Form WC-3 shall not be used to suspend benefits if the only issue is length of disability. In these cases, suspend benefits by filing a Form WC-2 or follow the procedure outlined in Rule 240. If liability is denied subsequent to commencement of payment, but within 60 days of due date of first payment of compensation, file Form WC-3 in addition.

O.C.G.A. §34-9-221(i): When compensation is being paid with or without an award and an employer or insurer elects to controvert on the grounds of a change in condition or newly discovered evidence, the employer shall, not later than 10 days prior to the due date of the first omitted payment of income benefits, file with the Board and the employee or beneficiary a notice to controvert the claim in a manner prescribed by the Board.

Board Rule 221(h)(2): If income benefits have been continued for more than 60 days after the due date of first payment of compensation, benefits may be suspended only on the grounds of a change in condition or newly discovered evidence. File Forms WC-2 or WC-2(a). When controverting a claim based on newly discovered evidence, file Form WC-3 also.

O.C.G.A. §34-9-108(b)(2): If any provision of Code Section §34-9-221, without reasonable grounds, is not complied with and a claimant engages the services of an attorney to enforce rights under that Code Section and the claimant prevails, the reasonable fee of the attorney, as determined by the Board, and the costs of the proceedings may be assessed against the employer.

INFORMATION FOR THE EMPLOYEE:

This claim is being controverted for the reason(s) indicated on the front of this form. If you disagree, you should request a hearing by sending Form WC-14 to the State Board of Workers’ Compensation at the address below. If you need a Form WC-14, please contact the State Board of Workers’ Compensation at the phone numbers listed below or visit the website.

STATE BOARD OF WORKERS' COMPENSATION

270 Peachtree Street, N.W. Atlanta, Georgia 30303-1299 In Atlanta: 404-656-3818

or: 1-800-533-0682

http://www.sbwc.georgia.gov

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).

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Form Characteristics

Fact Name Description
Form Purpose The WC-3 form serves as a "Notice to Controvert," allowing employers or insurers to officially contest the right to workers' compensation benefits for a claim.
Governing Law This form is governed by the Official Code of Georgia Annotated (O.C.G.A.) §34-9-221, which outlines requirements for disputing compensation claims.
Filing Deadline The form must be filed within 21 days of the employer's knowledge of the injury to prevent further complications, as stated in O.C.G.A. §34-9-221(d).
Notice Recipients Copies of the WC-3 form must be provided to the employee, all counsel involved, and anyone else with a financial interest in the claim.
Form Updates The latest revision of the WC-3 form was made in December 2018, ensuring that it remains in accordance with current laws and regulations.
Penalties for Misrepresentation Willfully making false statements on this form can lead to penalties of up to $10,000 per violation, according to O.C.G.A. §34-9-18 and §34-9-19.
Variety of Grounds The form allows for multiple grounds to be cited when disputing the claim, including reasons for disputing medical treatment or specific aspects of the claim.

Guidelines on Utilizing Georgia Wc 3

Filling out the Georgia WC-3 form is an important step in the workers' compensation process. It's essential to provide accurate and detailed information to ensure that your position regarding the controverted claim is clearly understood. Following these steps will help guide you through the process of completing this form.

  1. Start with Section A: Identifying Information. Fill in the claim number, the employee's last name, first name, and middle initial along with the date of injury.
  2. Provide the employee's mailing address, including city, state, and zip code. Include the employee's email address and phone number.
  3. Next, enter the employer’s name, phone number, and mailing address, ensuring you include the city, state, and zip code. Also, provide the employer's email address.
  4. In the section for the insurer or self-insurer, input the name, file number, and claims office information, along with the SBWC ID and their mailing address.
  5. Move to Section B: Controvert Types. Indicate your grounds for controverting by checking the appropriate box. Provide detailed reasons for your choice.
  6. If applicable, specify which part of the claim is being controverted and include the reasons for this action.
  7. Proceed to Section C: Certificate of Service. Here, certify that you have sent a copy of this notice to the employee, their attorney, and anyone else with a financial interest in the claim.
  8. Complete the certification by typing or printing your name, adding your signature, the date, phone number, and email address.
  9. Make sure to double-check all the entries for accuracy before submitting the form.
  10. Submit the original form to the State Board of Workers' Compensation. Provide copies to all parties involved, including the employee, medical providers, and any attorneys.

Once you have completed the WC-3 form, the next step is to file it promptly with the relevant authorities. Delays in submission could have consequences, so ensure that you adhere to the required timelines. Should any questions arise during this process, resources are available to assist you.

What You Should Know About This Form

What is the purpose of the Georgia WC-3 form?

The Georgia WC-3 form, known as the Notice to Controvert, serves a crucial function in the workers' compensation process. It allows employers or their insurers to formally contest an employee's claim for benefits. By using this form, they notify both the employee and the State Board of Workers' Compensation that they are disputing the claim or specific medical treatments associated with it.

Who needs to file the WC-3 form?

The responsibility to file the WC-3 form rests with the employer or their insurer. They must submit this notice to the State Board of Workers' Compensation when they have grounds to contest a claim within 21 days of becoming aware of the alleged injury. It is essential to comply with this timeline to avoid potential penalties.

What information must be included in the WC-3 form?

Every WC-3 form requires specific identifying information about both the employee and the employer. This includes names, mailing addresses, phone numbers, and details about the injury, such as the date it occurred. Additionally, the form must clearly state the reasons for disputing the claim or any associated medical treatments. This information is vital for the Board to understand the nature of the dispute.

What happens if the WC-3 form is not filed on time?

If the employer or insurer fails to file the WC-3 form within the required 21-day period, they may face significant consequences. This failure can lead to the assessment of attorney's fees, which means they might end up paying not only for the claim but also the legal costs incurred by the employee in pursuing it.

Can the WC-3 form be used for all types of claim disputes?

No, the WC-3 form is specifically designed for situations where the right to compensation is being formally contested. If the employer wishes to suspend benefits due to issues like the length of disability, a different form (the WC-2) must be used instead. Understanding the nuances of these forms is crucial to effectively managing workers' compensation claims.

What should an employee do if they disagree with the notice of controvert?

If an employee receives a WC-3 form and disagrees with its contents, they have the right to request a hearing. This can be accomplished by submitting Form WC-14 to the State Board of Workers' Compensation. It's crucial for employees to act quickly and be aware of their rights, as timely responses can significantly impact their ability to obtain the benefits they deserve.

Are there penalties for making false statements on the WC-3 form?

Yes, willfully making false statements on the WC-3 form to obtain or deny benefits is taken very seriously. Such actions can lead to criminal penalties of up to $10,000 per violation. This serves as a strong reminder for both employers and employees to provide accurate and truthful information when dealing with workers' compensation claims.

Common mistakes

When completing the Georgia WC-3 form, individuals often make notable mistakes that can affect the outcome of their claim. One common error is failing to provide complete identifying information. The form requires comprehensive details about the employee, employer, and insurer, including full names, addresses, and contact information. Leaving any of these fields incomplete can lead to delays or complications in processing the claim.

Another frequent mistake involves the selection of the correct types of controvert. The form includes specific sections where the individual must indicate the reason for controverting the claim. Some filers neglect to check the appropriate boxes or fail to clearly articulate the specific grounds for the controversy. This oversight can result in confusion and hinder the review process by the Georgia State Board of Workers' Compensation.

Moreover, individuals sometimes overlook the certificate of service section. The form requires a certification that copies have been sent to all relevant stakeholders, such as the employee, counsel, and any parties with a financial interest in the claim. Failing to fill out this section or not providing sufficient evidence of service can lead to complications and may even affect the legitimacy of the filing.

Inaccurate or missing signatures also represent a common error. Signatures are crucial for authenticating the document. A missing signature or an unsigned form can render the submission invalid. It is essential that the responsible party reviews the form thoroughly before submission to avoid such issues.

Additionally, formatting mistakes can occur. Submitting the form without adhering to formatting guidelines, such as failing to use the specified font or size, can impact readability and processing speed. It is advisable to maintain a professional and neat appearance for all official documents.

Moreover, individuals sometimes fail to adhere to the mandated timelines for filing. The WC-3 form must be filed within a specific timeframe following the onset of knowledge about the injury. Missing this deadline could potentially jeopardize the rights to contest claims. Timeliness is an essential aspect of the workers' compensation process.

Incorrectly stating the reasons for controverting the claim is another significant issue. Attachments or explanations must be consistent with the checked boxes. Discrepancies can raise questions regarding the credibility of the claim and may be subject to scrutiny by the Board.

Lastly, some filers neglect to keep copies of the submitted form. It is crucial for individuals to retain a personal copy of any documents submitted, along with proof of mailing or delivery. This practice serves to provide evidence and can be useful if there are disputes regarding submission or processing of the claim.

Documents used along the form

The Georgia WC-3 form, known as the Notice to Controvert, plays a crucial role in the workers' compensation process. It is often accompanied by other important documents that serve various purposes in the claims process. Here are six common forms related to the WC-3.

  • WC-1: Employer's First Report of Injury - This form is submitted by the employer to report an employee's injury to the State Board of Workers' Compensation. It includes essential details like the date of injury, nature of the injury, and initial medical treatment received.
  • WC-14: Request for Hearing - If there is a dispute in the claim, the employee can file this form to request a hearing. It triggers a formal review of the case by an administrative law judge.
  • WC-2: Notification of Suspension of Benefits - This form is used to suspend payments when there is a dispute about the ongoing necessity of benefits. It outlines the reasons for suspension and notifies the employee.
  • WC-2(a): Notice of Non-Payment of Benefits - Employers use this form to notify claimants that no benefits will be paid. It specifies the reason for this decision, such as the denial of the claim or failure to meet eligibility requirements.
  • WC-6: Employee’s Claim for Benefits - Employees use this form to formally file a claim for benefits under the Workers' Compensation Act. It provides details about the injury, treatment sought, and compensation requested.
  • WC-4: Supplementary Report of Injury - This form is used to update the Board on any additional information or changes regarding the initial injury report. It may include updates on treatment plans or changes in the employee’s condition.

Understanding these related forms is key for all parties involved in the workers' compensation process. Each form plays a specific role in ensuring that claims are processed correctly and fairly, allowing for a smoother resolution of disputes.

Similar forms

The Georgia WC-3 form, known as the Notice to Controvert, is crucial for initiating disputes related to workers' compensation claims. Several other documents serve similar purposes in guiding communication and clarifying issues in these claims. Here are four such documents:

  • Form WC-1: This is the Employer's First Report of Injury or Occupational Disease. It informs the State Board about a workplace injury or disease and initiates the claims process. Like the WC-3 form, it ensures that all involved parties are aware of the injury details, allowing for appropriate follow-up.
  • Form WC-2: This is the Notice of Suspension of Benefits. When an employer decides to suspend workers' compensation benefits, this form is used to officially report that action. Much like the WC-3, it involves notifying all relevant parties and provides a basis for potential disputes over the claim's status.
  • Form WC-14: Known as the Request for Hearing, this document is filed by employees who disagree with the controversions made on their claims. It formally initiates a request for a hearing to resolve the issues presented, similar in intent to the WC-3, which serves as notice of a dispute.
  • Form WC-4: This is the Employer's Notification of Change, which informs the Board and the claimant of changes regarding the claim, such as changes in medical treatment or wage loss. Like the WC-3, it promotes transparency and keeps all parties informed of new developments in the claim.

Each of these forms plays a unique role yet shares the common goal of facilitating communication and ensuring that all parties are informed throughout the workers' compensation process.

Dos and Don'ts

When filling out the Georgia WC-3 form, it is important to approach the task with care and attention to detail. Here is a list of things to do and avoid during the process:

  • Do: Provide complete identifying information for both the employee and employer.
  • Do: Clearly state the reasons for controverting the claim in Section B.
  • Do: Ensure all required fields are filled out accurately and legibly.
  • Do: Submit the completed form within the prescribed time frame of 21 days from the date of knowledge of the injury.
  • Do: Keep a copy of the form for your records and confirm it has been sent to all relevant parties.
  • Don't: Omit any pertinent information, as incomplete forms may delay proceedings.
  • Don't: Use vague language; be specific about the grounds for controverting the claim.
  • Don't: Wait too long to file. Make sure to meet the deadlines established by the State Board.
  • Don't: Assume all parties will understand your intentions; provide clear communication.
  • Don't: Falsify any information, as this can lead to serious consequences and penalties.

Misconceptions

There are several misconceptions surrounding the WC-3 form in Georgia’s workers' compensation system. Understanding the truth can help employees and employers navigate these requirements more effectively. Here are four common misconceptions:

  • Misconception 1: The WC-3 form is only used to deny a claim outright.
  • This is incorrect. The WC-3 form serves as a notice to controvert, meaning it can be used to challenge certain aspects of a claim. Employers or insurers might not fully deny a claim but could dispute specific medical treatments or other elements within the claim.

  • Misconception 2: The employer can submit the WC-3 form at any time without consequence.
  • This is not true. There is a strict deadline to file the WC-3 form. Employers must submit it within 21 days of their knowledge of an alleged injury or death. Failing to meet this deadline can result in penalties, including the risk of being ordered to pay attorney's fees.

  • Misconception 3: Submitting a WC-3 means that benefits will be suspended immediately.
  • This is a misunderstanding. While the WC-3 indicates intent to controvert, it does not automatically suspend benefits. If there are specific grounds for suspension, such as a change in condition, the appropriate forms must be filed, like the WC-2. The process is nuanced and involves specific steps.

  • Misconception 4: Completing the WC-3 form is a simple task that does not require any additional information.
  • In reality, completing the WC-3 accurately requires careful consideration and specific information related to the claim. Each section must be filled out according to the guidelines, and a failure to do so could lead to complications in the claims process.

Key takeaways

  • Complete Identifying Information: Fill out all sections accurately, including employee and employer details, to ensure the form is processed correctly.
  • Specify Grounds for Controversion: Clearly indicate the specific reasons for contesting the claim or medical treatment in Section B.
  • Timeliness is Key: The form must be filed within 21 days after the employer becomes aware of the injury to avoid penalties.
  • Service Certification: Make sure to certify that a copy of the notice has been sent to all relevant parties, including the employee and any other interested individuals.
  • Do Not Use for Length of Disability: If the only issue is the duration of disability, utilize Form WC-2 instead of WC-3.
  • Newly Discovered Evidence Requirement: If you are contesting a claim based on new evidence, file both Form WC-3 and a notice to controvert.
  • Seek Assistance if Needed: If you have questions or need clarification, contact the State Board of Workers' Compensation for guidance.