How to Fill Out Georgia Workers’ Comp Form WC-14 (w/Examples) + FAQs

Georgia Form WC-14 is the Notice of Claim/Request for Hearing/Request for Mediation that an injured worker files with the Georgia State Board of Workers’ Compensation (SBWC) to officially open a workers’ compensation claim. You file it to put the state on notice that you were hurt at work, to protect your benefits, and to ask for a hearing or mediation if the insurer fights you.

This one-page form does a lot of heavy lifting, and a single missed box or late filing can cost you medical care and lost-wage checks. Each year, thousands of Georgia workers report injuries, yet many lose benefits not because they were not hurt, but because they never filed a WC-14 within the one-year deadline. The good news is that the form is short, and once you understand each line, you can fill it out yourself and keep your claim alive.

Here is what you will learn in this guide:

• ✅ What every box on the official WC-14 asks and how to answer it correctly.
• ⏰ How the one-year statute of limitations works and the exceptions that can extend it.
• 📝 Three full filled-out examples that follow real injured workers from start to finish.
• 📬 How to file the form by ICMS, mail, or in person, plus the proof you should keep.
• 🚫 The most common mistakes that get claims delayed, denied, or dismissed.

What the Form Is and Who Must File It

The WC-14 is the form that turns a workplace injury into an official legal claim. Its full title printed at the top is Notice of Claim/Request for Hearing/Request for Mediation, and the version most filers see carries a revision date of 07/2011. The form goes to the State Board of Workers’ Compensation, the state agency that oversees every job-injury claim in Georgia under the Georgia Workers’ Compensation Act. Always download the current copy from the Board so you do not file an outdated layout.

You, the injured worker, must file this form. A common and dangerous myth is that your employer or its insurance company files your claim for you. Your employer files a separate form called the WC-1 (First Report of Injury), but that report does not count as your claim and does not stop the deadline clock. Only your WC-14 opens a claim in your name.

The law that requires timely filing is O.C.G.A. § 34-9-82, the one-year statute of limitations. In plain English, this statute says you generally have one year from the date of your accident to file your claim. If you ignore it, you lose the right to benefits forever, no matter how badly you were hurt. For example, Darnell hurt his back in March but waited 14 months to file, so the insurer raised the statute of limitations and the judge dismissed his claim. A frequent misconception is that telling your supervisor about the injury “starts the claim,” but verbal notice to a boss is not the same as filing a WC-14 with the Board.

The form also lets you do more than give notice. By checking a box, you can request a hearing before an Administrative Law Judge or ask for mediation. This means the same single page can both open your case and demand the dispute be resolved.

Before You Start: Documents and Information You Need

Filling out the WC-14 goes faster and cleaner when you gather your facts first. The Board cross-checks names, dates, and numbers, so a guess in any box can stall your claim. Collect these items before you open the form:

• Your full legal name and Social Security number, because the Board indexes your file by name and SSN, and a wrong digit can attach your injury to the wrong person.
• Your date of birth, since the form asks for it in Section A and the Board uses it to confirm identity.
• The exact date of injury, because this single date controls your one-year deadline and a wrong date can hand the insurer a statute-of-limitations defense.
• The county where you were hurt, since hearings are held in or near that county and the wrong county can send your case to the wrong judge.
• Your employer’s correct legal name and address, because the wrong entity name can delay service and let the real employer claim it was never notified.
• The insurer or self-insurer’s name and the five-digit SBWC number, which tells the Board exactly who must pay and respond.
• The claims office address and email, so your copies reach the adjuster handling your file.
• A description of the body part injured and your first date out of work, because these drive what benefits you can claim.
• The complete date of death and survivor names, if the case involves a fatal accident.
• Your attorney’s name and Georgia Bar number, if a lawyer represents you.

If any item is missing, do not leave the claim unfiled while you hunt for it. Missing the SBWC insurer number, for instance, will not void your form, but a missing or wrong date of injury can be fatal to the whole claim.

Where to Get the Form and How to Access It

You get the WC-14 directly from the State Board of Workers’ Compensation. The fastest route is the Board’s Board Forms page, where the WC-14 is offered as a fillable PDF you can type into and print. You can also download the form straight from the WC-14 download link on the agency site.

The form must be typed or printed in black ink, so the fillable PDF is your best friend. Filling it on a computer avoids messy handwriting that scanners and clerks can misread. If you print it blank and write by hand, use block letters and stay inside the boxes.

Georgia also runs an electronic system called ICMS (the Integrated Claims Management System) for filing and tracking claims. Attorneys and insurers file through ICMS, and many self-represented workers still file by mail or in person. A common misconception is that you must buy a “premium” version of the form from a third-party site; you never have to pay for the WC-14, because the official copy is free from the Board.

If you need to fix information after filing, you use a separate form, the WC-14a Request to Amend, rather than altering an already filed WC-14.

Step-by-Step: How to Fill Out Form WC-14 Line by Line

Work through the form in the order the boxes appear, from the top selection box down to the Certificate of Service at the bottom. Take each field one at a time and do not skip the boxes that look obvious.

The “Check Only One” Selection Box

At the very top, the form forces you to pick one of three options: Notice of Claim Only, Request Hearing/Notice of Claim, or Request for Mediation/Notice of Claim. This box tells the Board what you want it to do with the form.

To answer it, check the single box that matches your goal and never check more than one. Choose Notice of Claim Only if you simply want to open your claim and protect the deadline. Choose Request Hearing/Notice of Claim if the insurer has denied or stopped benefits and you want a judge to decide. Choose Request for Mediation/Notice of Claim if you want an informal settlement meeting first.

For example, Maria Lopez was denied medical care, so she checks Request Hearing/Notice of Claim to get her dispute in front of a judge. A nuance to know is that requesting a hearing also serves as your notice of claim, so you do not need to file a second form to do both. A common mistake is checking two boxes, which confuses the clerk and can bounce your form back unprocessed. The misconception here is that “Notice of Claim Only” is somehow weaker; it fully protects your rights, and you can request a hearing later when you need one.

Board Claim No., Employee Name, SSN, and Date of Injury (Header Row)

The top data row asks for the Board Claim No., Employee Last Name, Employee First Name, M.I., SSN or Board Tracking #, and Date of Injury. These tie your form to the correct file at the Board.

Enter your name exactly as it appears on your Social Security card, write your nine-digit SSN, and put the date of injury in month/day/year form. If a claim number already exists from your employer’s WC-1, write it in the Board Claim No. box; if you do not have one yet, leave it blank and the Board assigns it.

For example, Maria Lopez writes her last name Lopez, first name Maria, SSN 123-45-6789, and date of injury 02/10/2026. A nuance is that if you do not know your SSN tie-in or have only a Board Tracking number, you can enter that tracking number instead. The most common mistake is entering the wrong date of injury, which directly hands the insurer a statute-of-limitations defense and can get your claim dismissed. A misconception is that the claim number is something you must invent; you never make one up, because the Board issues it.

Section A: Claim Information (Employee Block)

Section A asks for your Birthdate, Address, City, State, Zip Code, County of Injury, and Employee E-mail. This block identifies you and tells the Board which county will host any hearing.

Fill in your birthdate in month/day/year form, your current mailing address, and the county where the accident happened, not the county where you live. Add an email so the Board and parties can reach you fast.

For example, Maria Lopez enters birthdate 03/14/1985, address 412 Oak Lane, city Marietta, state GA, zip 30060, and county of injury Cobb. A nuance is that if you use a P.O. Box, list it as your mailing address but be ready to give a physical location if asked. A common mistake is naming the wrong county of injury, which can move your hearing to a distant courthouse and delay your case. The misconception is that the county should be where you live; it is the county where you got hurt.

Section A: Employer Block

The employer block asks for the Name, Address, City, State, Zip Code, and Employer E-mail of the business you worked for. This tells the Board and insurer who employed you when you were hurt.

Use the employer’s full legal name, not a nickname or store number, and copy the address from a pay stub or the WC-1 if you have it. Add the employer email if you know it.

For example, Maria Lopez writes employer name Peachtree Logistics, Inc., address 900 Industrial Blvd, city Atlanta, state GA, zip 30318. A nuance is that large companies often operate under a parent name, so list the legal entity on your paycheck. A common mistake is using a “doing business as” name, which lets the real employer claim it was never properly served. The misconception is that the staffing agency and the worksite company are interchangeable; if a temp agency paid you, name the agency.

Section A: Insurer/Self-Insurer Block and SBWC#

This block asks for the insurer or self-insurer Name, the five-digit SBWC#, the Claims Office name and address, and the Claims E-mail. This identifies who actually pays and defends the claim.

Enter the insurance carrier’s name and its five-digit SBWC number, then list the claims office handling your file. If your employer is self-insured, write that and its SBWC number.

For example, Maria Lopez enters insurer Southern Mutual Insurance, SBWC# 12345, claims office Southern Mutual Claims, 100 Center St, Macon, GA 31201. A nuance is that if you cannot find the SBWC number, you can look it up through the Board or leave it blank and let the Board match it. A common mistake is sending the form to the wrong claims office, which means the adjuster never sees it and benefits stall. The misconception is that naming the insurer is optional; without it, no one is on the hook to pay.

Section A: Attorney Blocks

Two blocks cover the Attorney for Employee/Claimant and the Attorney for Employer/Insurer, each asking for Name, Address, City, State, Zip Code, GA Bar Number, and Attorney E-mail. These show who represents each side.

If you have a lawyer, your attorney fills in this block with their Georgia Bar number. If you file on your own (pro se), leave the employee attorney block blank, and you may also leave the employer’s attorney block blank if you do not know it.

For example, Marcus Greene hires a lawyer who enters his name, GA Bar No. 654321, and office address. A nuance is that filing pro se is fully allowed, so an empty attorney block never voids your form. A common mistake is writing a lawyer’s name without a Bar number, which can flag the entry. The misconception is that you must have an attorney to file; you do not, though help is wise for denied claims.

Section A Items 1–3: Body Part, First Date Disabled, and Fatal Date

These numbered items ask for 1. Part of Body Injured, 2. First Date Disabled, and 3. If Fatal Enter complete date of death along with a space to list Claimants for death benefits. They define the injury and any death claim.

Describe the body part plainly, give the first date you missed work because of the injury, and complete the fatal section only if the worker died. List survivors and attach extra sheets if there are several.

For example, Maria Lopez writes part of body injured lower back, first date disabled 02/11/2026, and leaves the fatal box blank. In a death case, Janet Carter enters date of death 01/20/2026 and lists herself as surviving spouse. A nuance is that if more than one body part was hurt, list them all so the insurer cannot deny the parts you left off. A common mistake is leaving the first date disabled blank, which can muddy your claim for income benefits. The misconception is that minor injuries do not need a body part listed; always name it to preserve future treatment.

Section B: Hearing/Mediation Issues

Section B is where you list the disputed issues, with checkboxes for Income Benefits (TTD, TPD, PPD with dates), Medical Benefits, Suspension/Termination Request, Late-Payment Penalties under §34-9-221(e), Assessed Attorney Fees under §34-9-108(b)(1), Catastrophic Designation under §34-9-108(b)(2), Appeal of Rehabilitation Decision, and Other. You complete this section only when you request a hearing or mediation.

Check each issue you want the judge to decide and add dates where the form asks for them. If you checked Notice of Claim Only at the top, you can leave Section B empty.

For example, Marcus Greene checks Income Benefits–TTD with dates starting 04/01/2026 and Medical Benefits because the insurer cut off both. A nuance is that catastrophic designation under §34-9-108(b)(2) unlocks lifetime benefits, so check it if your injury is severe and permanent. A common mistake is failing to list every disputed benefit, because a judge generally rules only on the issues you raised. The misconception is that you can add issues at the hearing without notice; you usually must list them on the WC-14 first.

Additional Board Claim Numbers

A line near Section B asks for Additional Board Claim Numbers which will be involved (if any) and reminds you to complete a separate WC-14 for each date of accident. This links related claims.

List any other claim numbers tied to the same dispute, and if you have two different injury dates, file two separate forms. Leave it blank if only one accident is involved.

For example, Marcus Greene lists a prior claim number 2024-098765 because his new injury aggravated an old one. A nuance is that separate accident dates always need separate WC-14 forms, never one combined form. A common mistake is cramming two injury dates onto a single form, which the Board will not process cleanly. The misconception is that all your injuries share one claim number; each accident date gets its own.

Section C: Affirmation of Employee

Section C is the Affirmation of Employee, where you attest that all information is true and correct to the best of your knowledge. This is your sworn statement.

Read it, then sign and date in the signature area tied to it. By signing, you confirm your answers are honest.

For example, Maria Lopez reviews her entries, then signs Section C. A nuance is that signing electronically through a fillable PDF is accepted when you file digitally. A common mistake is leaving the affirmation unsigned, which can make the form invalid. The misconception is that small errors are harmless; willfully making a false statement to obtain or deny benefits is a crime carrying penalties of up to $10,000 per violation under O.C.G.A. § 34-9-18 and § 34-9-19.

Section D: Entry of Appearance

Section D, Entry of Appearance, is where an attorney certifies a valid fee contract under Board Rule 108 or a filed WC-102B under Board Rule 102. This applies only when a lawyer represents you.

If you have a lawyer, your attorney completes this to confirm a fee agreement is on file or attached. If you file pro se, you leave Section D blank.

For example, Marcus Greene’s attorney checks Section D and notes the WC-102B is attached. A nuance is that the fee contract must already be filed or attached, or the entry is incomplete. A common mistake is an attorney signing without the fee contract on file, which can delay recognition of representation. The misconception is that pro se filers must complete this; you skip it entirely when you have no lawyer.

Section E: Certificate of Service

Section E, the Certificate of Service, certifies that you sent a copy of the form to all parties named above and to the State Board at 270 Peachtree St., NW, Atlanta, Georgia 30303-1299. It asks for your Print Name, Signature, Date, Phone Number, and E-mail.

Send copies to your employer and the insurer/claims office, then sign and date this section to prove you did. Fill in your phone and email so parties can reach you.

For example, Maria Lopez mails copies to Peachtree Logistics and Southern Mutual, then signs Section E with her phone 770-555-0148. A nuance is that you must serve the parties the same day you certify, since the certificate states you sent it “today.” A common mistake is filing with the Board but never serving the insurer, which can delay or derail your hearing. The misconception is that the Board forwards your form to the insurer for you; service is your job.

Three Filled-Out Examples Using Real Scenarios

These three scenarios follow named workers through the most common WC-14 situations. Each table shows what they enter in the key sections of the form.

Scenario 1: Maria Lopez — Notice of Claim Only (back injury, on time)

Form Section	What Maria Enters
Check Only One	Notice of Claim Only
Employee Name / SSN	Lopez, Maria / 123-45-6789
Date of Injury	02/10/2026
Birthdate / County of Injury	03/14/1985 / Cobb
Employer	Peachtree Logistics, Inc., Atlanta, GA
Insurer / SBWC#	Southern Mutual Insurance / 12345
Item 1 Part of Body / Item 2 First Date Disabled	Lower back / 02/11/2026
Section B Issues	Left blank (notice only)
Section E Certificate of Service	Signed, copies mailed to employer and insurer

Scenario 2: Marcus Greene — Request for Hearing (benefits denied)

Form Section	What Marcus Enters
Check Only One	Request Hearing/Notice of Claim
Employee Name / SSN	Greene, Marcus / 987-65-4321
Date of Injury	03/28/2026
County of Injury	Fulton
Employer / Insurer	Metro Builders LLC / Statewide Comp Insurance, SBWC# 54321
Item 1 Part of Body	Right shoulder and neck
Section B Issues	Income Benefits–TTD (04/01/2026); Medical Benefits
Section D Entry of Appearance	Attorney certifies WC-102B attached
Section E Certificate of Service	Signed, copies served on insurer and claims office

Scenario 3: Janet Carter — Death Benefits (fatal accident)

Form Section	What Janet Enters
Check Only One	Request Hearing/Notice of Claim
Employee Name / SSN	Carter, David / 456-78-9012
Date of Injury	01/18/2026
Item 3 Date of Death	01/20/2026
Claimants for Death Benefits	Janet Carter, surviving spouse, 55 Pine St, Savannah, GA
County of Injury	Chatham
Employer / Insurer	Coastal Freight Co. / Harbor Insurance, SBWC# 67890
Section B Issues	Income Benefits (dependency); Medical/Funeral expenses
Section E Certificate of Service	Signed by Janet, copies served on all parties

How to File the Completed Form

Georgia gives you more than one way to get the WC-14 to the State Board, and you should keep proof for every method. Whichever channel you use, you must also serve copies on the employer and insurer the same day.

• By mail: Send the signed form to the State Board of Workers’ Compensation at 270 Peachtree St., NW, Atlanta, Georgia 30303-1299. There is no filing fee. Use certified mail with return receipt so you have dated proof the Board received it, and keep the green card.
• In person: You can hand-deliver the form to the Board’s Atlanta office at the same Peachtree Street address during business hours. Ask for a date-stamped copy as your proof of filing.
• Electronically (ICMS): Attorneys and insurers file through the Board’s ICMS electronic system, which is the fastest channel and gives instant confirmation. Pro se workers commonly file by mail or in person, but you can call the Board at 404-656-3818 or 1-800-533-0682 to ask about electronic options.

No matter the channel, there is no charge to file a WC-14, and you should never pay a third-party site to submit it. Processing times vary, but when you request a hearing, the Board typically assigns a judge and schedules the hearing within about 60 days. Always keep a complete copy of the form and your proof of service in a safe place.

What Happens After You File

Once the Board receives your WC-14, it logs the form and, if you requested a hearing, assigns your case to an Administrative Law Judge. The hearing is usually set within about 60 days and held in or near the county of injury you listed.

A copy of your form also reaches the employer and insurer, which puts them on notice that an official claim now exists. In many cases the insurer responds by approving benefits or by filing its own forms to accept or controvert the claim. If the insurer accepts, you may start receiving checks without a hearing.

If the insurer denies or disputes your claim, the judge holds a hearing where both sides present evidence, and the judge issues an award deciding what benefits you receive. Remember that under O.C.G.A. § 34-9-100, for injuries on or after July 1, 2007, a claim with no medical or income benefits paid is dismissed by law if no hearing is held within five years of the injury. Mediation is an alternative where a neutral Board mediator helps you and the insurer settle without a full hearing.

Mistakes to Avoid When Filling Out the Form

Small errors on the WC-14 cause big problems because each box feeds the legal record. Watch for these specific mistakes:

• Filing after the one-year deadline, which lets the insurer kill the claim under the statute of limitations.
• Entering the wrong date of injury, which can create a fatal statute-of-limitations defense.
• Checking more than one box at the top, which confuses the clerk and can bounce the form.
• Naming a “doing business as” name instead of the legal employer, which lets the real employer deny service.
• Listing the county where you live instead of the county of injury, which can send your case to the wrong court.
• Leaving Section B blank when you request a hearing, which leaves the judge with no issues to decide.
• Forgetting to serve the insurer, which delays or derails your hearing.
• Failing to sign Section C or Section E, which can make the form invalid.
• Skipping injured body parts, which lets the insurer deny treatment for the parts you left off.
• Combining two accident dates on one form, which the Board will not process cleanly.
• Altering an already filed WC-14 instead of using the WC-14a, which creates a defective record.
• Paying a third-party website for a “premium” form, which wastes money on a free document.

Do’s and Don’ts

Keep these quick rules in mind as you complete and file the form.

Do’s

• Do file within one year of your injury, because missing the deadline can permanently bar your claim.
• Do type or print in black ink, because the Board requires it and clean entries avoid misreads.
• Do list every injured body part, because unlisted parts can be denied later.
• Do serve the employer and insurer the same day, because the Certificate of Service swears you did.
• Do keep certified-mail or date-stamped proof, because you may need to prove timely filing.
• Do use the WC-14a to fix errors, because altering a filed form creates a defective record.

Don’ts

• Don’t assume your employer files your claim, because only your WC-14 protects your rights.
• Don’t guess the date of injury, because a wrong date can trigger a statute-of-limitations defense.
• Don’t check two boxes at the top, because the form forces one choice.
• Don’t leave the affirmation or service section unsigned, because that can void the form.
• Don’t pay for the form, because the Board provides it free.
• Don’t ignore Section B when disputing benefits, because the judge rules only on listed issues.

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

Many Georgia workers file the WC-14 themselves, while others hire an attorney. The right choice depends on how contested your claim is.

Pros of filing pro se

• It costs nothing, because the form is free and you pay no attorney fee up front.
• It is fast for simple notice-only claims, because you control the timing.
• It keeps full settlement control in your hands, because no one negotiates for you.
• It works well when the insurer already accepts the claim, because little is in dispute.
• It builds your understanding of the process, because you handle each step.

Cons of filing pro se

• You may list issues incorrectly in Section B, because the rules are technical.
• You risk missing deadlines or exceptions, because the statute of limitations is unforgiving.
• You face experienced insurance defense lawyers alone, because the other side is represented.
• You may undervalue a settlement, because you lack benefit-calculation experience.
• You handle hearings without trial skills, because the judge expects evidence and procedure.

FAQs

Do I have to file the WC-14 myself?

Yes. Your employer files only the WC-1 First Report of Injury, which does not count as your claim. Filing the WC-14 with the State Board is your responsibility as the injured worker.

Is there a deadline to file Form WC-14?

Yes. You generally have one year from the date of injury under O.C.G.A. § 34-9-82, though authorized medical treatment or paid income benefits can extend that deadline in certain cases.

Do I write the county where I live in the County of Injury box?

No. You write the county where the accident happened, not where you live, because hearings are held in or near the county of injury you list.

Can I check more than one box at the top of the form?

No. The form says “Check only one,” so you pick a single option, and requesting a hearing already serves as your notice of claim.

Do I need a lawyer to fill out the WC-14?

No. You can file pro se, and an empty attorney block never voids your form, but legal help is wise when the insurer denies or disputes your claim.

Is there a fee to file the WC-14?

No. Filing with the State Board is free, and you should never pay a third-party website that claims to sell a “premium” version of the form.

Do I leave Section B blank if I only want to give notice?

Yes. If you checked “Notice of Claim Only,” you can leave the Hearing/Mediation Issues section empty, since no dispute is being raised yet.

Should I list every body part I injured?

Yes. List all injured body parts in Item 1, because the insurer can deny treatment for any part you fail to include on the form.

Do I put my SSN if I already have a Board Tracking number?

Yes. The box accepts your SSN or your Board Tracking number, so you can enter either one to tie the form to your file.

Can I use one WC-14 for two different injury dates?

No. You complete a separate WC-14 for each date of accident, because the Board cannot process two injury dates cleanly on one form.

Do I serve the insurer myself, or does the Board do it?

Yes, you serve it yourself. The Certificate of Service certifies that you sent copies to all parties the same day, so the Board does not do this for you.

Can I change information after I file the WC-14?

No, you do not alter the filed form. You file a separate WC-14a Request to Amend, because changing a filed WC-14 creates a defective record.

Does giving false information on the form carry a penalty?

Yes. Willfully making a false statement to obtain or deny benefits is a crime with penalties up to $10,000 per violation under O.C.G.A. § 34-9-18 and § 34-9-19.

Will my claim ever expire after I file it?

Yes. Under O.C.G.A. § 34-9-100, a claim with no benefits paid is dismissed by law if no hearing is held within five years of the injury date.