MCIM Claim Forms - Georgia
First Report of Injury
NOTE: Adobe Acrobat Approval, Standard, or Professional version 5 or newer is required for viewing this form.
NOTE: Adobe Acrobat Approval, Standard, or Professional version 5 or newer is required for viewing this form.
| ga_froi-_wc-1__2023.pdf |
Please report injuries to MCIM as soon as possible.
Wage Statement
This form is necessary in all lost time cases where wages will be paid to the injured worker. The Workers' Compensation Act requires that we have 13 weeks of prior wage information whenever possible to determine the rate at which they will be paid.
This form is necessary in all lost time cases where wages will be paid to the injured worker. The Workers' Compensation Act requires that we have 13 weeks of prior wage information whenever possible to determine the rate at which they will be paid.
Mileage Reimbursement
Petición de Reembolso del Kilometraje
This form is included for the worker’s convenience in requesting reimbursement for mileage incurred traveling to medical appointments in connection with the injury. Injured Worker’s can submit thoroughly completed forms to their examiner.
Petición de Reembolso del Kilometraje
This form is included for the worker’s convenience in requesting reimbursement for mileage incurred traveling to medical appointments in connection with the injury. Injured Worker’s can submit thoroughly completed forms to their examiner.
