How to Fill Out Georgia Workers’ Comp Form WC-1 (w/Examples) + FAQs

Georgia’s Form WC-1, the Employer’s First Report of Injury or Occupational Disease, is the document an employer and its insurer use to officially report a work injury to the Georgia State Board of Workers’ Compensation and to start (or deny) benefits. The employer fills out Section A right after learning about an injury, and the insurer or self-insurer then completes Section B, C, or D before filing with the Board.

This form is the front door to a workers’ comp claim, and a single wrong box can delay a paycheck, trigger a state penalty, or wreck a worker’s medical care. Georgia employers report tens of thousands of job injuries each year, and the law gives the insurer only 21 days to get this form filed with the Board after the employer learns of lost time.

Here is what you will learn in this guide:

• 📋 What every box on the current Revision 7/2021 WC-1 asks and how to answer it
• ⏱️ The exact deadlines (immediate, 21-day, and 24-hour) and the penalties for blowing them
• 🧮 How to calculate the Average Weekly Wage and weekly benefit without getting it wrong
• 🧾 Three full filled-out examples for accepted, medical-only, and denied claims
• ❓ Field-level FAQs that answer the questions filers actually search for

What the Form Is and Who Must File It

Form WC-1 is the very first official record in a Georgia workers’ compensation claim. It tells the insurer and the State Board that a worker got hurt or sick on the job, who that worker is, how it happened, and what the employer or insurer plans to do about it. The form is filed by the employer and the insurer or self-insurer, not by the injured worker, which surprises many people. A worker who wants to start their own claim files a separate Form WC-14, Notice of Claim instead.

The form exists because Georgia law, found in O.C.G.A. Title 34, Chapter 9, requires prompt reporting of work injuries so benefits can begin fast. The agency that receives the completed form is the State Board of Workers’ Compensation in Atlanta. The deadline that governs it is the 21-day rule, and the penalty for ignoring it can reach up to $10,000 per violation under O.C.G.A. § 34-9-18 and § 34-9-19 for willful false statements, plus separate late-filing penalties.

These pieces all connect. The employer’s quick report feeds the insurer the facts. The insurer uses those facts to pick Section B, C, or D and to file on time. The Board uses the filing to open a claim number and watch the deadline. Miss one link, and the whole chain breaks, which usually hurts the injured worker first.

A quick word on who is “covered.” Most Georgia businesses with three or more workers must carry workers’ comp coverage. That means most employers will face this form at some point, and getting comfortable with it now saves stress later.

Before You Start: Documents and Information You Need

Gather everything before you open the form. A half-filled WC-1 that sits on a desk while you hunt for a wage record is exactly how employers miss the 21-day window. Here is the pre-filing checklist:

• Employee’s full legal name, address, birthdate, and phone. The Board matches the worker to the claim with this; a wrong name can split one injury into two confused files.
• Employer FEIN (Federal Employer Identification Number). The insurer and Board use it to link the claim to the right business; a missing FEIN stalls processing.
• Insurer or self-insurer name and SBWC ID# (the five-digit Board number). A wrong SBWC ID# sends the filing to the wrong carrier and can blow the deadline.
• Date the employer first knew about the injury. This date starts the 21-day clock, so it must be exact.
• Date of injury and the first full day the employee missed work. These drive whether income benefits are owed.
• Payroll records for the 13 weeks before the injury. You need them to calculate the Average Weekly Wage; without them you cannot set the correct benefit rate.
• The wage rate and how it is paid (per hour, day, week, or month). A wrong unit here throws off the entire benefit math.
• Treating physician and facility names and addresses. The form asks for who is treating the worker; leaving it blank can look like care was denied.
• NAICS code and nature of business. The Board uses these for industry tracking; guessing can flag the filing.
• County and time of injury. These set jurisdiction and detail; vague answers invite follow-up letters.

If any item is missing, do not wait. Report the injury to your insurer by phone first, then file the paper once you fill the gaps. The phone call protects the worker even while you finish the form.

Where to Get the Form and How to Access It

The only safe place to get the current WC-1 is the State Board’s Board Forms page. The Board posts a fillable PDF you can type into, which matters because the form itself says it must be typed or printed in black ink. Old copies float around online, so confirm the version before you use one.

The current version is Revision 7/2021, printed in the bottom corner of the form. This detail is not a footnote you can skip. Beginning October 1, 2025, the Board began returning outdated forms, and several Board forms were amended effective July 1, 2025. If you file an old WC-1, expect it to bounce back, which eats into your 21 days.

You can download the PDF, type your answers, and save it. Many insurers and self-insurers also file the data electronically through EDI (Electronic Data Interchange), which is the standard channel for high-volume carriers. If you are a small employer, you usually do not file with the Board yourself at all. You send your completed Section A to your insurer, and the insurer files.

If the form or the law confuses you, the Board runs a help line at 404-656-3818 in Atlanta or 1-800-533-0682 toll free. Use it before you guess. A two-minute call beats a rejected filing.

Step-by-Step: How to Fill Out Form WC-1 Line by Line

The WC-1 is two pages. Page one holds the fill-in fields, grouped into Section A (Identifying Information) and the action sections B, C, and D. Page two is instructions. Work top to bottom and do not skip a box just because it looks blank or optional.

Top Header: Board Claim No., Employee Name, and Date of Injury

The top strip asks for the Board Claim No., the Employee Last Name, First Name, M.I., and Date of Injury. In plain English, this is the label that tells everyone whose claim this is. To answer it, leave the Board Claim No. blank if this is the first filing, since the Board assigns that number; fill the rest using the worker’s legal name and the date the injury happened in MM/DD/YYYY format.

For example, Carlos Mendez writes his last name Mendez, first name Carlos, middle initial R, and date of injury 03/14/2026. A common edge case is a worker who uses a nickname or a married-versus-maiden name; always use the legal name from payroll, not the nickname coworkers use. A frequent mistake is leaving Date of Injury blank for an occupational disease that built up over time; in that case enter the date the worker first knew the illness was work-related, because a blank date stalls the file. The misconception here is that the Board Claim No. is something you create. It is not; the Board issues it, and writing your own number confuses the record.

Section A — Employee Identifying Information

This block asks for the worker’s sex (Male/Female), Birthdate, Phone Number, Employee E-mail, and full Mailing Address (City, State, Zip Code). In plain terms, it is the worker’s contact card. Fill each field exactly, using MM/DD/YYYY for the birthdate and the worker’s current home address, not the job site.

For example, Carlos Mendez checks Male, enters birthdate 07/22/1990, phone (770) 555-0143, and his home address in Marietta, GA 30060. An edge case is a worker without an email; leave the email blank rather than inventing one, since a fake address breaks Board contact. A common mistake is entering the work address instead of the home address, which means benefit checks and notices go to the wrong place. The misconception is that this section is for the employer’s information; it is only for the employee, and mixing the two scrambles the claim.

Section A — Employer Information

Here the form wants the Employer Name, NAICS Code, Nature of Business, Mailing Address, Phone Number, Employer FEIN, City, State, Zip Code, and Employer E-mail. This is the business’s identity card on the claim. Enter the legal business name, the federal FEIN exactly as it appears on tax filings, and a short trade description like Construction or Retail.

For example, Peachtree Framing LLC enters NAICS code 238130, nature of business Construction, FEIN 58-1234567, and its office address in Marietta, GA 30062. An edge case is a staffing agency worker, where the legal employer may be the agency, not the host site; list the entity that carries the coverage. The most common mistake is a wrong or missing FEIN, which keeps the Board from linking the claim to the correct insured employer and delays everything. A misconception is that the NAICS code is optional; the Board uses it for industry data, and a blank can flag the form for review.

Section A — Insurer / Self-Insurer and Claims Office

This block captures the Insurer/Self-Insurer Name, Insurer/Self-Insurer FEIN, Insurer/Self-Insurer File #, Claims Office Name, Claims Office FEIN #, Claims Office Phone, Claims Office E-mail, SBWC ID# (five digit no.), and the claims office Mailing Address. In plain English, it tells the Board who is paying and who is handling the file. The employer usually leaves the SBWC ID# and file number to the insurer, but should know the carrier’s name.

For example, Statewide Mutual Insurance enters its SBWC ID# 48217, its claims office in Atlanta, GA 30303, and a claims phone of (404) 555-0199. An edge case is a self-insured employer, which checks the self-insurer role and enters its own SBWC ID#. The biggest mistake on this block is a wrong SBWC ID#, because the Board routes the claim by that five-digit number and an error sends it to the wrong carrier. The misconception is that any insurance ID works here; only the official five-digit SBWC ID# is correct, not a policy number.

Section A — Employment / Wage

This area asks for the Date Hired by Employer, Job Classified Code No., Number of Days Worked Per Week, Wage rate at time of Injury (with checkboxes for per Hour, per Day, per Week, or per Month), the Insurer Type Code, the List Normally Scheduled Days Off, and an insurer-role check for I – Insurer, S – Self-insurer, or Group Fund. This block sets up the wage math. Enter the hire date, the raw wage rate, and check the matching pay unit.

For example, Carlos Mendez was hired 01/15/2024, works 5 days per week, earns $24.00 with the per Hour box checked, and has Saturday and Sunday listed as days off. An edge case is a salaried worker; convert salary to the right unit and check per Week or per Month to match. A common mistake is checking the wrong pay unit, such as marking per Week for an hourly wage, which corrupts the Average Weekly Wage downstream. The misconception is that this single rate sets the benefit; it does not, because the true benefit comes from the 13-week wage average, not one line.

Section A — Injury / Illness & Medical

This is the heart of Section A. It asks for the Time of Injury (am/pm), County of Injury, Date Employer had knowledge of Injury, the First Date Employee Failed to Work a Full Day, whether the worker got Full Pay on Date of Injury (Yes/No), whether the injury happened on Employer’s premises (Yes/No), the Type of Injury/Illness, the Body Part Affected, a free-text How Injury or Illness Occurred, the Treating Physician name and address, the Initial Treatment Given (None, Minor: By Employer, Minor: Clinical/Hospital, Emergency Room, Hospitalized > 24hrs), the Hospital/Treating Facility, the Returned to Work date and wage, the complete Date of Death if Fatal, and the Report Prepared By, Telephone Number, and Date of Report.

In plain English, this tells the full story of what happened and who is treating it. Be specific and factual in the “how it occurred” box, naming the task and the cause.

For example, Carlos Mendez enters time 10:15 am, county Cobb, date employer had knowledge 03/14/2026, first full day missed 03/17/2026, checks No for full pay, Yes for on premises, type Fracture, body part Right wrist, and writes “Fell from a ladder while installing roof trusses.” He lists treating physician Dr. Anita Rao and checks Emergency Room for initial treatment.

An important edge case is the Date Employer had knowledge field, which differs from the date of injury for diseases or delayed reports; this date, not the injury date, starts the 21-day clock. A common and costly mistake is a vague “how it occurred” entry like “hurt at work,” which gives the insurer grounds to question the claim and slows acceptance. The misconception is that “Date Employer had knowledge” and “Date of Injury” are always the same; they often are not, and mixing them can make a timely filing look late.

Section B — Income Benefits

Section B is completed by the insurer when indemnity (income) benefits are paid or due, including salary in lieu of comp. It asks whether the claim was Previously Medical Only (Yes/No), the Average Weekly Wage, the Weekly benefit, the Date of disability, the Date of first Payment, the Compensation paid, the Date salary paid, the Penalty paid, and the period Benefits Are Payable From… Until, with checkboxes for Temporary total disability, Temporary partial disability, or Permanent partial disability of __% for __ weeks. In plain English, this is the section that says, “We accept this claim and here is the money.”

To answer it, calculate the Average Weekly Wage from the 13 weeks before the injury, then set the weekly benefit at two-thirds of that wage, up to the state maximum. The form notes that Form WC-6 must be filed if the weekly benefit is less than the maximum.

For example, the insurer enters AWW $960.00, weekly benefit $640.00, date of disability 03/17/2026, date of first payment 03/28/2026, and checks Temporary total disability. An edge case is a worker with two jobs; concurrent wages from all covered employers may raise the AWW. A common mistake is leaving out overtime or bonuses when figuring the AWW, which underpays the worker by thousands over the claim’s life. The misconception is that the weekly benefit equals the worker’s full pay; it is two-thirds of the AWW, capped by state law, not the whole check.

Section C — Notice to Controvert Payment of Compensation

Section C is checked when the insurer denies the claim in full or in part, and it includes a line that reads “Benefits will not be paid because:” In plain terms, this is the denial box, and what gets written on that line is the legal reason the claim is being refused. The insurer must give a specific ground, not a vague brush-off.

For example, an insurer writes “Independent medical exam shows the back condition is degenerative and not caused by the reported lifting incident.” An edge case is a partial controvert, where the insurer accepts the medical part but denies lost wages; the reason must spell out exactly what is denied. A common mistake is a one-word reason like “disputed,” which an administrative law judge may reject as inadequate and which hands the worker an easy challenge. The misconception is that a denial ends the case; it does not, because the worker can file a Form WC-14 within one year and demand a hearing.

Section D — Medical Only Injury

Section D is checked when no indemnity benefits are due and the claim has not been controverted, meaning the worker gets medical care but no wage checks because they did not miss enough work. In plain English, it says, “We are paying the doctor, but there are no lost-wage benefits right now.” Check this box when the injury is real and covered but the worker lost little or no time.

For example, Tasha Wells cut her hand, got stitches, and returned the same day, so the insurer checks Section D and pays the ER bill only. An edge case is a worker who starts as medical-only and later misses more than seven days; the insurer must then switch to Section B and pay income benefits. A common mistake is checking Section D when the worker has already missed over a week of work, which illegally withholds owed income benefits. The misconception is that medical-only means a minor or fake injury; it simply means no lost-wage benefits are due yet, and serious care can still be paid.

Final Signature Block

The bottom of page one asks the Insurer/Self-Insurer to Type or Print the Name of Person Filing Form, then provide a Signature, Date, Phone Number, and E-mail. In plain English, this is the official sign-off that the information is true. The person who completed the action section signs and dates it.

For example, claims adjuster Gloria Tan prints her name, signs, dates it 03/28/2026, and adds her phone and email. An edge case is electronic filing through EDI, where a digital submission record stands in for an ink signature. A common mistake is leaving the signature or date blank, which makes the filing incomplete and can void it. The misconception is that any office worker can casually sign; the signer is certifying accuracy under penalty of law, since a willful false statement carries fines up to $10,000 per violation.

Three Filled-Out Examples Using Real Scenarios

Below are three common fact patterns showing what each filer enters in the key fields of the WC-1.

Scenario 1: Accepted Lost-Time Claim (Carlos Mendez, Roofer)

Carlos fell from a ladder, broke his wrist, and missed three weeks. The insurer accepts the claim and pays income benefits in Section B.

Form Section	What Carlos’s Filing Shows
Employee Name / Date of Injury	Mendez, Carlos R / 03/14/2026
Employer / FEIN	Peachtree Framing LLC / 58-1234567
Insurer / SBWC ID#	Statewide Mutual / 48217
Date Employer Had Knowledge	03/14/2026
First Full Day Missed	03/17/2026
Type of Injury / Body Part	Fracture / Right wrist
How It Occurred	Fell from ladder installing roof trusses
Section Used	Section B — Income Benefits
Average Weekly Wage / Weekly Benefit	$960.00 / $640.00
Benefit Type Checked	Temporary total disability

Scenario 2: Medical-Only Claim (Tasha Wells, Cashier)

Tasha cut her hand on a box cutter, got stitches at urgent care, and finished her shift. No lost time, so the insurer uses Section D.

Form Section	What Tasha’s Filing Shows
Employee Name / Date of Injury	Wells, Tasha M / 04/02/2026
Employer / FEIN	Greenline Grocers Inc / 58-7654321
Insurer / SBWC ID#	Coastal Casualty / 51904
Date Employer Had Knowledge	04/02/2026
Full Pay on Date of Injury?	Yes
Type of Injury / Body Part	Laceration / Left hand
Initial Treatment Given	Minor: Clinical/Hospital
Returned to Work Date	04/02/2026 (same day)
Section Used	Section D — Medical Only
Income Benefits	None due at this time

Scenario 3: Controverted (Denied) Claim (Derrick Pope, Warehouse Worker)

Derrick reports back pain he blames on lifting, but an exam suggests a pre-existing condition. The insurer denies the claim in Section C.

Form Section	What Derrick’s Filing Shows
Employee Name / Date of Injury	Pope, Derrick L / 04/20/2026
Employer / FEIN	Summit Logistics LLC / 58-2468135
Insurer / SBWC ID#	Statewide Mutual / 48217
Date Employer Had Knowledge	04/21/2026
Type of Injury / Body Part	Strain / Lower back
How It Occurred	Reported pain after lifting 50 lb boxes
Section Used	Section C — Notice to Controvert
Reason for Denial	IME shows degenerative condition, not work-related
Worker’s Next Step	May file Form WC-14 within one year
Signed By	Adjuster, dated and certified

How to File the Completed Form

The WC-1 moves in steps, and the channel depends on who you are. The employer’s job is the first move, and the form is clear: do not send the WC-1 to the State Board directly as an employer. Send it to your insurance company or self-insurer claims office.

• Employer to insurer (immediate). The employer completes Section A and sends it to the carrier’s claims office right away by the carrier’s preferred method, often email, fax, or an online portal. Keep a dated copy and a send confirmation as your proof of filing. There is no fee.
• Insurer to the Board by EDI (electronic). High-volume insurers and self-insurers file the data with the Board through EDI, the standard electronic channel. Processing is near-immediate, and the system returns an acknowledgment that serves as proof. There is no filing fee.
• Insurer to the Board by mail. When paper is used, the insurer files with the State Board of Workers’ Compensation, 270 Peachtree Street N.W., Atlanta, Georgia 30303-1299. Send it certified mail and keep the green card as proof. No fee applies.
• Serious or fatal injuries (phone first). For serious injuries, report immediately by telephone to the insurer’s claims department, then file the written form. Fatalities require reporting within 24 hours.

In every channel, the insurer must complete Section B, C, or D and file with the Board, plus mail a copy of both sides of the form to the employee and all counsel of record, within 21 days of the employer’s knowledge of disability, injury, or death. Keep proof of every send.

What Happens After You File

Once the insurer files, the State Board opens a claim and assigns a Board Claim No. that follows the case for life. If Section B was completed, the worker starts getting weekly income benefits and approved medical bills get paid. The first check should arrive promptly, and the form lists the payable period and benefit type.

If Section D was completed, the worker gets medical benefits only, with no wage checks for now. That can change if the worker later misses more than seven days, which forces the insurer to switch to Section B. The worker should watch their lost time closely and tell the adjuster the moment it crosses a week.

If Section C was completed, the claim is denied, and the clock starts on a dispute. The worker who disagrees must file a Form WC-14, Notice of Claim, within one year of the accident with the State Board to keep the right to a hearing. After that, an administrative law judge can review the denial reason written in Section C.

In all cases, both sides should keep a copy. Errors on the WC-1 are common, and the worker has every right to request the filed form from the Board and challenge anything that is wrong.

Mistakes to Avoid When Filling Out the Form

• Using an outdated form. The Board returns old versions, so confirm Revision 7/2021, or your filing bounces and burns days.
• Missing the 21-day deadline. Filing late exposes the insurer to penalties and delays the worker’s first check.
• Wrong SBWC ID#. The five-digit error routes the claim to the wrong carrier and can void timely filing.
• Blank or wrong Employer FEIN. The Board cannot link the claim to the right business, freezing processing.
• Confusing “Date Employer had knowledge” with “Date of Injury.” This mix-up can make an on-time filing look late and start penalties.
• Checking the wrong pay-unit box. Marking per Week for hourly pay corrupts the Average Weekly Wage and the benefit rate.
• Leaving out overtime or bonuses in the AWW. It underpays the worker by thousands across the claim.
• Vague “how it occurred” entry. A line like “hurt at work” hands the insurer grounds to question the claim.
• A weak Section C reason. A one-word denial like “disputed” can be tossed by a judge and helps the worker win.
• Checking Section D when the worker missed over a week. This illegally withholds owed income benefits.
• Skipping the signature or date. An unsigned form is incomplete and may be rejected.
• Sending the employer’s WC-1 straight to the Board. Employers send to the insurer first; the form says so plainly.

Do’s and Don’ts

Do:

• Do report the injury to your insurer immediately, because the law ties penalties to delay.
• Do type or print in black ink, since the form demands it and faded copies get rejected.
• Do use the worker’s full legal name, so the Board matches the claim correctly.
• Do pull 13 weeks of payroll before figuring the AWW, because guessing underpays the worker.
• Do give a specific, factual “how it occurred” line, since it speeds acceptance.
• Do keep dated proof of every filing, because you may need to prove you met the 21-day rule.

Don’t:

• Don’t use an old form version, because the Board returns it and you lose time.
• Don’t invent a Board Claim No., since the Board assigns it and a fake number confuses the file.
• Don’t leave the SBWC ID# blank or wrong, because the claim will misroute.
• Don’t write a vague denial reason in Section C, since a judge can reject it.
• Don’t mix employer and employee fields, because it scrambles the claim.
• Don’t sign without checking the facts, since a willful false statement risks up to $10,000 per violation.

Pros and Cons of Filing on Your Own vs. With Help

Small employers and adjusters often debate whether to handle the WC-1 in-house or lean on a TPA, broker, or attorney.

Pros of filing on your own:

• Speed, because you control the timeline and can hit the 21-day rule without waiting on a third party.
• Cost savings, since you pay no outside handling fee.
• Direct knowledge, because you know your worker and the incident best.
• Simplicity for medical-only claims, where Section D is short and low-risk.
• Control of the record, since you keep your own proof of filing.

Cons of filing on your own:

• Calculation risk, because the Average Weekly Wage and benefit math are easy to botch.
• Legal exposure, since a wrong Section C denial can invite penalties and a hearing.
• Deadline risk, because a busy office can miss the 21 days.
• Form-version risk, since you may not track the latest revision.
• Higher stakes on disputed claims, where professional help often prevents costly errors.

FAQs

Who actually files the WC-1, the worker or the employer?

No. The injured worker does not file it. The employer completes Section A and the insurer or self-insurer files the form with the State Board, usually within 21 days.

Do I send the WC-1 to the State Board myself as an employer?

No. Employers send the completed Section A to their insurer or self-insurer claims office. The insurer, not the employer, files the form with the Board.

Is there a deadline to file the WC-1?

Yes. The insurer must file with the Board within 21 days of the employer’s knowledge of disability, injury, or death, and serious or fatal injuries require faster reporting.

What is the current version of the form?

Yes, it matters: the current version is Revision 7/2021, printed in the corner. Starting October 1, 2025, the Board returns outdated versions, so confirm before filing.

Do I write the date of injury or the date I learned of it in the knowledge box?

No, they are not always the same. The “Date Employer had knowledge” box takes the date you learned of the injury, which starts the 21-day clock, not the injury date.

What goes in the SBWC ID# field?

Yes, it is specific: enter the insurer’s five-digit State Board ID number, not the policy number or any other insurance ID, or the claim will misroute.

Which pay-rate box do I check for a salaried worker?

Yes, convert it: enter the salary and check per Week or per Month to match how it is paid, then let the 13-week average set the true benefit.

Do I check Section B or Section D for a worker who missed no time?

No income is due, so check Section D for a medical-only injury. Use Section B only when income benefits are paid or owed.

Is a one-word reason enough in the Section C denial box?

No. A vague reason like “disputed” can be rejected by a judge. State the specific, factual ground for denying the claim in full or in part.

Does the worker lose the claim if Section C denies it?

No. A denial is not the end. The worker can file a Form WC-14 within one year of the accident and request a hearing before an administrative law judge.

Must I include overtime and bonuses in the Average Weekly Wage?

Yes. Leaving out overtime, bonuses, or concurrent-job wages underpays the worker and can be challenged and corrected later, sometimes for thousands of dollars.

Can I file the WC-1 electronically?

Yes. Most insurers and self-insurers file the data with the Board through EDI, the standard electronic channel, which returns an acknowledgment that serves as proof.

What happens if I file the WC-1 late?

Yes, there are consequences: late filing can trigger State Board penalties and delays the worker’s first benefit check, which often draws a complaint.

Does a signature really matter on this form?

Yes. The signer certifies the information is true, and a willful false statement is a crime carrying fines up to $10,000 per violation under O.C.G.A. § 34-9-18 and § 34-9-19.