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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. Board Claim No. Employee Last Name Employee First Name M. I. Date of Injury A. CLAIM INFORMATION Birthdate Body Part Injured Address Phone Number EMPLOYEE Employee E-mail City Name State INSURER/ SELF- INSURER Zip Code SBWC five digit CLAIMS OFFICE Claims Office E-mail ATTORNEY FOR EMPLOYEE/CLAIMANT GA Bar Number EMPLOYER/INSURER Attorney E-mail...
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