Online Notice of Claim Filing

EMPLOYER'S NOTICE OF CLAIM FOR REIMBURSEMENT FROM THE SUBSEQUENT INJURY TRUST FUND (Official Code of GA Ann. 34-9-362)

In support of such notice and without precluding the right to establish further facts as may be developed, the following allegations are set forth subject to proof at a Hearing.

Enter Claim Information
All the fields indicated with an asterisk (*) are required.
*Claim Number:
Insurer File Number:
*Date of Injury:
	Date of Injury must be no later than June 30, 2006
Self Injured:	Yes No
*Employee Last Name:
*First Name:
Middle Initial:
*Address:

*City:
*State:
*Zip Code:
*Employer Name:
*Address:

*City:
*State:
*Zip Code:
*Insurer (as shown on policy):
Address:

City:
State:
Zip Code:
Telephone Number:	Ext.
*1. Is this report ONLY to toll the Statute of Limitations AND for the purpose of protecting the employer's right to pursue this claim at a later date?	Yes No
*2. Current Status (select at least one)	Employee’s claim has been controverted Medical only case Lost time case
*3. Has form WC-1 been filed with State Board of Workers' Compensation?	Yes No
I hereby certify that I am authorized to submit this form and that the information is true and correct. I further understand that a typed version of my name is being accepted as my original signature pursuant to the Georgia Electronic Records and Signature Act.
*Authorized Signature:
*Date:
*Claim Handled By:
*Mailing Address:

*City:
*State:
*Zip Code:
NOTE: O.C.G.A. §14-2-129 provides that "a person who signs a document he knows is false in any material respect with intent that the document be delivered to the Subsequent Injury Trust Fund for filing shall be guilty of a misdemeanor and, upon conviction thereof, shall be punished by a fine not to exceed $500.00."

Online Notice of Claim Filing

Online Notice of Claim Filing

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