Get the free WC-104 - State Board of Workers' Compensation - Georgia.gov - sbwc georgia

WC-104 NOTICE TO EMPLOYEE OF MEDICAL RELEASE TO RETURN TO WORK WITH RESTRICTIONS OR ...

How to fill out wc-104 - state board

How to fill out wc-104 - state board:

1. Begin by gathering all necessary information such as the employee's name, address, and occupation. This information will need to be accurately filled out in the appropriate sections of the form.
2. In section 1, provide details about the employer, including their name and address. If the employer is self-insured, indicate this as well.
3. Proceed to section 2 and enter the employee's personal data, including their name, address, date of birth, and contact information.
4. In section 3, specify the date and time of the injury or occupational disease, as well as the location where it took place.
5. Next, describe the injury or occupational disease in detail. Include information such as the specific body parts affected, the cause of the injury, and any contributing factors.
6. Section 4 requires you to provide details regarding the medical care the employee has received. Include the name and address of the healthcare provider, the date of treatment, and a description of the services rendered.
7. If the employee has been absent from work due to the injury or disease, indicate the duration of the absence in section 5.
8. Section 6 is dedicated to wage replacement benefits. Provide information about the employee's compensation rate and whether any payments have already been made.
9. In section 7, summarize any additional information relevant to the claim, such as previous injuries or any other pertinent details.
10. Before submitting the form, ensure that all information is accurate, legible, and complete. Sign and date the form in the appropriate sections.

Who needs wc-104 - state board:

1. Employers who have employees that suffer from work-related injuries or occupational diseases need wc-104 - state board. This form is required to report such incidents to the state board to initiate the workers' compensation claim process.
2. Employees who have experienced a work-related injury or occupational disease may also need wc-104 - state board. They would need this form to report the incident and ensure that their claim is properly documented and processed.
3. Healthcare providers treating employees with work-related injuries or occupational diseases may also require wc-104 - state board. It is important for them to accurately document the medical care provided and submit the form to the state board for reimbursement and compliance purposes.

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What is wc-104 - state board?

wc-104 - state board is a form used to report work-related injuries and illnesses to the state board for tracking and record-keeping purposes.

Who is required to file wc-104 - state board?

Employers are required to file wc-104 - state board for every work-related injury or illness that occurs within their organization.

How to fill out wc-104 - state board?

To fill out wc-104 - state board, employers must provide detailed information about the injured employee, the nature of the injury, and the circumstances surrounding the incident.

What is the purpose of wc-104 - state board?

The purpose of wc-104 - state board is to track and monitor work-related injuries and illnesses, ensure proper care and compensation for injured employees, and prevent future incidents.

What information must be reported on wc-104 - state board?

Information that must be reported on wc-104 - state board includes details about the injured employee, the date and location of the incident, the nature of the injury, and any medical treatment provided.