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WC-14 NOTICE OF CLAIM GEORGIA STATE BOARD OF WORKERS COMPENSATION Check only one NOTICE OF CLAIM ONLY REQUEST HEARING / NOTICE OF CLAIM REQUEST FOR MEDIATION / NOTICE OF CLAIM Complete a new Form WC-14 to add an additional employer insurer or to add date of injury. 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. WC-14 REVISION. 07/2011 For...
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