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WC-25 APPLICATION FOR LUMP SUM / ADVANCE PAYMENT GEORGIA STATE BOARD OF WORKERS' COMPENSATION APPLICATION FOR LUMP SUM / ADVANCE PAYMENT When you receive this completed form, you must file any objection
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01
Start by opening the wc-025doc form on your computer or printing it out.
02
Fill in your personal information in the designated fields, such as your name, address, and contact details.
03
Provide the necessary details of the incident or accident for which you are submitting the form. Include the date, time, and location of the incident.
04
Describe the circumstances surrounding the incident in detail. Be clear and concise in your explanations, providing any relevant information that may help in the assessment of the claim.
05
If applicable, provide information about any witnesses to the incident and their contact details, if available.
06
If you received medical treatment as a result of the incident, provide details of the healthcare provider, any diagnoses given, and the treatment received.
07
Specify the type of benefits you are seeking, such as medical expenses, lost wages, or disability benefits.
08
Sign and date the form to indicate your agreement with the information provided.
Who needs wc-025doc:
01
Individuals who have experienced a work-related injury or illness may need to fill out the wc-025doc form.
02
Employees who need to claim workers' compensation benefits for medical expenses, lost wages, or other related expenses would require this form.
03
Employers or insurance companies involved in the claims process may also need the wc-025doc form to evaluate and process the claim accurately.
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