Georgia Workers’ Comp Form WC-104 is the Notice to Employee of Medical Release to Return to Work With Restrictions, and the employer or insurer files it to tell an injured worker that their authorized treating physician has cleared them for light-duty work. The form starts the legal clock that can later convert an injured worker’s benefits from temporary total disability (TTD) to the lower temporary partial disability (TPD) rate.
The stakes are high on both sides. If you are the claims handler, one wrong box or a missed deadline can block the conversion and cost the insurer weeks of full-rate benefits. If you are the injured worker who just got this form in the mail, it is a warning that a pay cut may be coming, and you have a short window to act. Georgia courts have made clear that because the Workers’ Compensation Act is in derogation of common law, every line of this form must be strictly construed, and even a 20-year-old process still trips up seasoned adjusters.
This guide walks you through the official WC-104 form field by field, with real named examples and the exact consequences of each choice.
Here is what you will learn:
- đź“„ What each box on the WC-104 means and the exact words to write in it.
- ⏱️ How the strict 60-day deadline works and what happens if you miss it.
- 👨‍⚕️ Why the release must come from the authorized treating physician and no one else.
- 🧾 Three full filled-out examples that follow real filers from start to finish.
- ⚖️ The mistakes that void the form and the FAQs injured workers ask most.
What the Form Is and Who Must File It
Form WC-104 is a one-page notice created by the State Board of Workers’ Compensation (SBWC), the state agency that runs Georgia’s workers’ comp system. Its job is narrow but powerful. The form tells an injured worker, in writing, that the doctor who is treating their work injury has said they can return to work with limits or restrictions. The employer or its insurance carrier files the form, never the injured worker.
The legal engine behind the form is O.C.G.A. § 34-9-104, the “change in condition” statute. That law says when a non-catastrophic injured worker can do light-duty work for 52 straight weeks, the Board treats it as a “change in condition for the better.” At that point the worker drops from the temporary total disability rate to the lower temporary partial disability rate. The same law caps total-disability benefits at 78 aggregate weeks once the worker is able to do limited work.
The WC-104 is the trigger that lets the insurer make this change unilaterally, meaning without a hearing or a judge’s order. State Board Rule 104 sets the procedure: the employer or insurer must file the form with the Board and serve it on the worker within 60 days of the light-duty release. Miss the rule and the conversion fails.
Who actually fills it out? In most cases it is the claims adjuster or a defense attorney working for the insurer. The injured worker is the one served with it. So this guide speaks to both: the filer who must get every box right, and the worker who must read it closely and protect their benefits.
This form does not stand alone. It works with the WC-2 (the form that actually changes the benefit amount), the WC-200a (which appoints a treating physician), the WC-240 (a formal light-duty job offer), and the supporting medical report from the doctor. Check the revision date printed in the bottom corner of the PDF before you use it, because the Board updated several rules effective July 1, 2025, and you must use the current version.
Before You Start: Documents and Information You Need
Filling out the WC-104 takes minutes, but only if you have gathered the right paperwork first. Missing even one item can void the filing or leave you unable to prove you served the worker on time. Pull these together before you open the form.
- The board claim number (file number). The Board indexes everything by this number, and leaving it blank can cause the form to be misfiled or rejected. If the claim has not yet been assigned a number, the date of injury becomes the key identifier.
- The exact date of injury. This must match the date already on file with the Board, because a mismatch makes the Board unable to tie the form to the right claim.
- The employee’s full legal name and current address. You need this to complete the notice and to serve the worker, and a wrong address means your service is invalid.
- The employer’s legal name and the insurer/servicing agent name. The form must show who is sending the notice, since the worker has a right to know who is acting against their benefits.
- The light-duty release from the authorized treating physician. This is the single most important attachment, because the form is worthless without the medical proof behind it.
- A written list of the work restrictions. The statute requires you to explain the limitations, so copy them word for word from the doctor’s note (for example, no lifting over 10 pounds).
- The date the worker was released to restricted work. This date sets the conversion date, so getting it wrong shifts the entire benefit timeline.
- The employee attorney’s name and address, if the worker is represented. You must serve counsel too, and skipping the attorney can defeat the whole notice.
- Your method-of-service proof. Decide now whether you will serve by email, certified mail, or by enclosing the form with a benefit check, because you may have to prove service later.
If any of these is missing, stop and get it before filing. A WC-104 sent without the supporting medical report is the most common reason a conversion gets thrown out at a hearing.
Where to Get the Form and How to Access It
The only safe place to get the form is the State Board’s own website. Download the current PDF directly from the WC-104 form page, which always hosts the latest revision. Avoid copies floating around on third-party blogs, because an outdated version may be missing fields the Board now requires.
You can complete the form two ways. You can type into the fillable PDF on a computer, which produces a clean, readable notice and reduces handwriting errors. Or you can print it and fill it in by hand using black ink and block capital letters, which works but raises the risk of an unreadable date or name.
Most professional filers complete and submit the WC-104 electronically through the Board’s ICMS online portal, the Integrated Claims Management System. Registered insurers, servicing agents, and attorneys file there. If you are an unrepresented employer without an ICMS account, you can still file by mail or email.
The form is free. There is no filing fee for the WC-104, and the Board never charges to download or submit any of its claim forms. If a website asks you to pay for the form, you are on the wrong site.
A quick word on the worker’s side: if you received a WC-104 and want a blank copy to understand it, pull the same official PDF from the SBWC site so you are reading the exact form your insurer used.
Step-by-Step: How to Fill Out Form WC-104 Line by Line
The WC-104 is short, but each field carries legal weight. Complete every box, because Georgia courts have voided conversions over a single blank or wrong entry. Use the exact labels printed on the form and work top to bottom.
Box 1: Board Claim Number / State Board File Number
This field asks for the case number the State Board assigned to the claim. Write the number exactly as it appears on prior Board correspondence or the WC-1 first report, with no extra spaces. For example, claims adjuster Denise Carter writes 2024-098765 in the claim number box for her injured worker’s file. If no number has been assigned yet because the claim is new, leave it blank and rely on the date of injury and employee name to identify the case. The most common mistake here is transposing two digits, which sends the form to the wrong file and means the worker is never officially noticed. Many filers wrongly believe the claim number is optional; it is not, and an unindexed form may as well not exist.
Box 2: Employee Name
This field asks for the full legal name of the injured worker. Write the first, middle, and last name as they appear on the claim, in the order the form requests, using block capitals if filling by hand. For example, Marcus J. Reynolds goes in the employee name field for a warehouse worker hurt on the job. If the worker uses a nickname or has changed names since the injury, use the legal name on the original claim and note the alias nearby so service is not challenged. The common mistake is writing only a first and last name when the claim file lists a middle initial, which can create doubt about identity. People wrongly think a small name variation is harmless, but a mismatch gives a worker’s attorney an opening to attack the notice.
Box 3: Date of Injury
This field asks for the date the work injury happened. Enter it in MM/DD/YYYY format, matching the date already on file with the Board to the day. For example, 03/14/2024 is the date of injury for a worker who fell from a ladder that morning. If the claim involves a repetitive injury with no single date, use the date of disablement that the Board already recognizes on the claim. The common mistake is guessing the date or pulling it from memory, which creates a mismatch with the Board’s records and stalls processing. Filers often assume any date “close enough” will do, but the Board ties forms to claims by exact date, so precision is required.
Box 4: Employer Name and Insurer / Servicing Agent
This field asks who is sending the notice: the employer and the insurance carrier or servicing agent handling the claim. Write the employer’s full legal business name and the insurer’s name on the lines provided, not abbreviations or internal codes. For example, Peachtree Logistics LLC and insurer Southeast Casualty Insurance Co. fill these lines for Marcus’s claim. If the employer is self-insured, write the company name and note “self-insured” so the worker knows where the notice comes from. The common mistake is listing only the third-party administrator’s name and omitting the employer, which can confuse the worker about who is acting. People wrongly believe the insurer alone needs to be named, but the worker is entitled to see the employer identified too.
Box 5: Date Released to Return to Work With Restrictions
This field asks for the exact date the authorized treating physician released the worker to restricted duty. Enter it in MM/DD/YYYY format, copied straight from the doctor’s note or medical record. For example, 05/02/2026 is the release date that adjuster Denise enters after reading the treating doctor’s report. This date is the conversion date under Rule 104(d), so getting it right is critical, because the date of conversion is the release date, not the filing date. The common mistake is using the date the office typed the report instead of the date the doctor released the worker, which can shift the conversion window by weeks. Filers often believe the conversion starts when they file the form, but the law fixes it to the release date, so a late filing within 60 days still relates back to that release.
Box 6: Explanation of Limitations or Restrictions
This field asks you to spell out the work limits the doctor ordered. Copy the restrictions word for word from the medical release, in plain terms the worker can understand, such as no lifting over 10 pounds, no climbing, sit or stand as needed. For example, attorney Janet Cole writes the full restriction list for her insurer client rather than a vague summary. The statute itself requires this explanation, so a blank or fuzzy entry can void the notice. The common mistake is writing only “light duty” without detail, which fails the statutory requirement to explain the restrictions and gives the worker grounds to challenge the form. People wrongly think attaching the doctor’s note is enough on its own, but the form must also state the restrictions on its face.
Box 7: Notice of the General Terms of O.C.G.A. § 34-9-104
This field is the printed statutory notice that tells the worker how the change-in-condition law works. You usually do not write here; the form already contains the required language explaining the 52-consecutive-week and 78-aggregate-week rules. For example, when Denise prints the form for Marcus, this section already informs him that 52 weeks of light-duty capacity can drop him to the partial-disability rate. Read it to confirm it matches the current statute, because using an outdated form may carry the wrong notice language. The common mistake is deleting or altering this language on an edited copy, which strips the worker of the explanation the law guarantees. People wrongly assume this block is filler text, but it is the heart of the statutory notice and must stay intact.
Box 8: Signature, Title, and Date of the Preparer
This field asks the person completing the form to sign, give their title, and date it. Sign your name, print your title (such as Claims Adjuster or Attorney for Employer/Insurer), and enter the date in MM/DD/YYYY format. For example, Denise Carter, Claims Adjuster, 05/10/2026 completes the signature block on Marcus’s form. If a defense attorney prepares the form, the attorney signs and lists the firm. The common mistake is leaving the date blank, which makes it hard to prove the form was prepared and served within the 60-day window. People wrongly think an electronic submission through ICMS removes the need to sign, but the certifying signature still belongs on the form.
Box 9: Certificate of Service
This field documents that you served the worker and any attorney with the form. List the names and addresses served, the method (email, certified mail, or hand delivery), and the date of service. For example, Denise writes that she served Marcus J. Reynolds by email and his attorney Janet Cole by certified mail on 05/10/2026. Because you may have to prove service later, use email when possible, or enclose the form with a benefit check so a cashed check shows receipt. The common mistake is serving the worker but forgetting the attorney, which alone can defeat the notice for a represented claimant. People wrongly believe filing with the Board counts as serving the worker, but filing and service are two separate, required steps.
Three Filled-Out Examples Using Real Scenarios
These three scenarios show how different filers complete the WC-104 from start to finish. Each follows one named person through the form and the choices they make.
Scenario 1: Timely conversion after a clean 52-week light-duty release. Adjuster Denise Carter handles a back-injury claim for warehouse worker Marcus Reynolds, whose authorized treating physician released him to light duty on May 2, 2026.
| Form Section | What Denise Enters |
|---|---|
| Board Claim Number | 2024-098765 |
| Employee Name | Marcus J. Reynolds |
| Date of Injury | 03/14/2024 |
| Employer / Insurer | Peachtree Logistics LLC / Southeast Casualty Insurance Co. |
| Date Released to Restricted Work | 05/02/2026 |
| Explanation of Restrictions | No lifting over 10 lbs; no climbing; sit/stand as needed |
| Signature, Title, Date | Denise Carter, Claims Adjuster, 05/10/2026 |
| Certificate of Service | Served Marcus by email; attorney by certified mail, 05/10/2026 |
| Supporting Medical Attached | Yes — Dr. Patel’s 05/02/2026 release note |
Scenario 2: A late WC-104 filed past the 60-day window. Adjuster Tom Bishop discovers a light-duty release dated February 1, 2026 buried in records he reviews in late April, more than 60 days later.
| Form Section | What Tom Enters |
|---|---|
| Board Claim Number | 2025-044120 |
| Employee Name | Angela R. Smith |
| Date of Injury | 11/06/2025 |
| Date Released to Restricted Work | 02/01/2026 |
| Date Form Prepared | 04/28/2026 (87 days later — too late) |
| Explanation of Restrictions | Seated work only; no overhead reaching |
| Risk Flag | Filing is past 60 days; conversion likely barred |
| Recommended Action | Seek a fresh release and file a new timely WC-104 |
| Certificate of Service | Served, but timeliness will be challenged |
Scenario 3: A catastrophic claim where the WC-104 does not apply. Defense attorney Janet Cole reviews a severe spinal-cord injury and realizes the worker is designated catastrophic under O.C.G.A. § 34-9-200.1(g).
| Form Section | What Janet Determines |
|---|---|
| Board Claim Number | 2026-001003 |
| Employee Name | David L. Okafor |
| Date of Injury | 01/09/2026 |
| Injury Classification | Catastrophic (spinal cord) |
| Light-Duty Release | None — worker cannot perform restricted work |
| WC-104 Applicable? | No — statute excludes catastrophic claims |
| Conversion to TPD? | Not available |
| Correct Path | Continue TTD; do not file WC-104 |
| Note to File | Reassess only if designation is later removed |
How to File the Completed Form
The WC-104 has two separate jobs: it must be filed with the Board and served on the worker, both within 60 days of the release. Doing one without the other voids the conversion. There is no filing fee on any channel.
Online (ICMS portal). Registered insurers, servicing agents, and attorneys upload the form and the supporting medical through the ICMS portal. Processing is near-instant, and the system date-stamps your submission, which becomes your proof of filing. Keep the confirmation screen or email.
By mail. Send the form to the State Board of Workers’ Compensation, 270 Peachtree Street, NW, Atlanta, GA 30303-1299. There is no fee. Use certified mail with return receipt so you keep proof of the filing date, and allow several days for delivery and indexing.
By email/electronic service on the worker. To serve the employee, email is the preferred method because it creates a timestamp you can prove. If the worker has no email, enclose the WC-104 with a disability benefit check, since a cashed check proves receipt. Certified mail to the worker and attorney is the more expensive backup.
In person. You may hand-deliver the form to the worker or counsel, but get a signed, dated acknowledgment of receipt as your proof of service. Keep a copy of every filed and served version in the claim file for at least the life of the claim.
Whatever channel you use, save your proof of both filing and service. At a hearing, the burden is on the employer/insurer to show the form was filed and served within 60 days, and missing proof is the same as missing the deadline.
What Happens After You File
Filing the WC-104 does not by itself cut the worker’s check. The form is a notice and a clock-starter, not the conversion itself. The worker keeps receiving temporary total disability benefits while the light-duty release continues.
Once the worker has been capable of restricted work for 52 consecutive weeks (or once 78 aggregate weeks of total-disability benefits have been paid while the worker could do limited work), the insurer can actually convert benefits to the partial-disability rate by filing a WC-2. It is best practice to attach the WC-104 and the supporting medical to that WC-2. Failure to file the WC-2 means benefits cannot be converted at all, even with a perfect WC-104 on file.
Because conversion relates back to the release date under Rule 104(d), the date the worker was released, not the filing date, controls when the lower rate begins. If the worker returns to light-duty work during the 52 weeks and then stops again, that working time may not count toward the 52 weeks, and a new WC-104 is usually needed. The worker can fight back by requesting a hearing, by showing the release was not from the authorized treating physician, or by proving the form was untimely or incomplete.
Mistakes to Avoid When Filling Out the Form
- Missing the 60-day deadline. Filing or serving the form after 60 days from the release blocks the unilateral conversion entirely.
- Using a referral doctor’s release. A release from anyone other than the authorized treating physician does not support the form, so the conversion fails.
- Forgetting to attach the medical report. A WC-104 with no supporting release is routinely thrown out at a hearing.
- Leaving the restrictions vague. Writing only “light duty” without detail fails the statute’s requirement to explain the limits and voids the notice.
- Using the wrong release date. Entering the report’s typing date instead of the doctor’s release date shifts the conversion window and can invalidate timing.
- Serving the worker but not the attorney. For a represented worker, skipping counsel defeats service and the notice fails.
- Confusing filing with service. Filing with the Board does not serve the worker, and both separate steps are required.
- Never filing the follow-up WC-2. Without the WC-2, benefits legally cannot be converted no matter how perfect the WC-104.
- Filing on a catastrophic claim. The conversion process does not apply to catastrophic cases, so the form has no effect there.
- Editing the statutory notice language. Deleting or altering the printed O.C.G.A. § 34-9-104 explanation strips the worker of required notice and voids the form.
- Keeping no proof of service. Without a timestamp, email, or cashed check, you cannot prove timely service at a hearing.
- Using an outdated form version. An old PDF may lack fields the Board now requires after the July 1, 2025 rule changes.
Do’s and Don’ts
Do:
- Do monitor medical records closely, because the 60-day clock starts the moment the authorized treating physician issues the release.
- Do copy the restrictions word for word from the doctor’s note, since the statute demands a clear explanation of the limits.
- Do serve the worker by email when possible, because it gives you a provable timestamp.
- Do serve the worker’s attorney too, since skipping counsel defeats the notice for a represented claimant.
- Do attach the supporting medical report, because the form is worthless without the proof behind it.
- Do calendar the eventual WC-2 conversion, since the WC-104 alone never changes the benefit amount.
Don’t:
- Don’t rely on a referral physician’s release, because only the authorized treating physician’s release supports the form.
- Don’t wait past 60 days, since a late filing bars the unilateral conversion.
- Don’t write only “light duty,” because vague restrictions void the statutory notice.
- Don’t alter the printed statutory language, since the worker is entitled to that exact explanation.
- Don’t assume filing equals service, because the Board and the worker must each receive the form.
- Don’t discard your proof of service, since you carry the burden to prove timely service later.
Pros and Cons of Filing on Your Own vs. With Help
For employers and adjusters, the choice is handling the WC-104 in-house versus using defense counsel. For injured workers, it is responding alone versus hiring a workers’ comp attorney.
Pros of handling/responding on your own:
- It costs nothing, since the form is free and you avoid attorney fees.
- A simple, clean light-duty release is straightforward to document.
- You keep full control of the timing on routine claims.
- Fast filing through ICMS needs no outside coordination.
- For workers, reading the form yourself helps you spot an early benefit cut.
Cons of handling/responding on your own:
- Georgia courts strictly construe the form, so one error can void months of work for an insurer.
- The case law on 52 versus 78 weeks is genuinely confusing, even for adjusters.
- A worker who misses the meaning of the form may lose benefits without a fight.
- Proving service correctly is technical, and mistakes are hard to fix later.
- Catastrophic and referral-doctor issues often need a lawyer’s judgment to get right.
WC-104 vs. WC-2: How They Work Together
These two forms are easy to confuse, but each does a different job in the conversion process.
| Form WC-104 | Form WC-2 |
|---|---|
| Notifies the worker of a light-duty release | Actually changes the benefit amount or status |
| Must be filed within 60 days of the release | Filed when the 52 or 78 weeks are met |
| Starts the conversion clock | Completes the conversion to the TPD rate |
| Requires the supporting medical attached | Should attach the WC-104 and medical |
| Does not by itself reduce the check | Without it, benefits cannot be converted |
FAQs
Is the WC-104 the form that actually cuts my benefits?
No. The WC-104 only notifies you of a light-duty release and starts the clock. Your benefits are not reduced until the insurer later files a WC-2 after 52 or 78 weeks.
Does the employer really have only 60 days to file it?
Yes. Under Board Rule 104, the employer or insurer must file and serve the WC-104 within 60 days of the authorized treating physician’s light-duty release, or the unilateral conversion fails.
Can a release from any doctor support the WC-104?
No. The release must come from the authorized treating physician. A referral specialist’s release does not count unless that doctor was appointed by filing a WC-200a.
Do I write only “light duty” in the restrictions box?
No. The statute requires a real explanation of the limits, so you must list specifics like no lifting over 10 pounds or no climbing, copied from the doctor’s note.
What date goes in the “date released to restricted work” box?
Yes, there is a precise answer: use the date the doctor actually released the worker, not the date the report was typed, because that release date sets the conversion date.
Does filing the form with the Board also count as serving me?
No. Filing and service are two separate steps. The employer must both file with the Board and serve you (and your attorney) within the 60 days.
Do I have to leave the claim number box blank if there is no number yet?
Yes. If the Board has not assigned a number, leave it blank and rely on the date of injury and your name, but add the number as soon as it exists.
Does the WC-104 apply to catastrophic injury claims?
No. The unilateral conversion process under O.C.G.A. § 34-9-104 applies only to non-catastrophic claims, so the form has no effect on a catastrophic designation.
Can the insurer convert my benefits without ever filing a WC-2?
No. Even with a perfect WC-104 on file, the insurer must file a WC-2 to actually convert benefits, and skipping it means no conversion occurs.
Does the conversion start on the day the form is filed?
No. Under Rule 104(d), conversion relates back to the date you were released to restricted work, not the date the form was filed or served.
If I return to light-duty work and then stop, does that time still count?
No. Time spent working may not count toward the 52 consecutive weeks, and the insurer usually must file a new WC-104 to restart the clock.
Can I challenge a WC-104 I think is wrong?
Yes. You can request a hearing and challenge the form on timing, a missing medical report, a referral-doctor release, or vague restrictions, and a strict-construction error may void it.
Do I have to sign the WC-104 if I am the injured worker?
No. The injured worker does not sign the WC-104. The adjuster or attorney preparing it signs the form; you are the party being served with it.
Is there a fee to file the WC-104?
No. The State Board charges no fee to download, file, or serve the WC-104 through any channel, including the ICMS portal, mail, or email.
Related reading
- How to Fill Out Georgia Form DOL-800 (w/Examples) + FAQs
- How to Fill Out Georgia Workers’ Comp Form WC-1 (w/Examples) + FAQs
- How to Fill Out Georgia Workers’ Comp Form WC-14 (w/Examples) + FAQs
- How to Fill Out Georgia Workers’ Comp Form WC-200a (w/ Examples) + FAQs
- How to Fill Out Georgia Workers’ Comp Form WC-240 (w/Examples) + FAQs
- How to Fill Out Georgia Workers’ Comp Form WC-243 (w/Examples) + FAQs
- How to Fill Out California WCAB DWC-AD 1 (w/Examples) + FAQs