Georgia Employer's First Report of Injury of Occupational DiseaseGeorgia Employer's First Report of Injury of Occupational Disease
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EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE

GEORGIA STATE BOARD OF WORKERS' COMPENSATION
EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE
NOTE: FAILURE TO SUBMIT THIS REPORT TO INSURER IMMEDIATELY MAY RESULT IN PENALTY. MUST BE TYPED OR PRINTED IN BLACK INK.
Board Claim No.
Employee Last Name
Employee First Name
M.I.
Social Security Number
Date of Injury

A. IDENTIFYING INFORMATION
0 Male
0 Female

EMPLOYEE

Birthdate

Phone Number

Address

Employee E-mail
City

Name

EMPLOYER

State

NAICS Code

Address

Nature of Business (Trade, Transport, Mfg.,etc.)

Phone Number

City

State

Zip Code

Insurer/Self-Insurer FEIN

Name

CLAIMS OFFICE

Employer FEIN

Employer E-mail

Name

INSURER /
SELF-INSURER

Claims Office FEIN #

SBWC ID# (five digit no.)

Address

Insurer/ Self-Insurer File #

Claims Office Phone

Claims Office E-mail

City

Date Hired by Employer

Job Classified Code No.

State

Zip Code

Wage rate at time of
Injury or Disease:

Number of Days Wo