The employer is required to submit a notarized knowledge
affidavit containing information outlined in the following format:
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NOTICE TO EMPLOYER: If this document is pre-prepared and
submitted to you for signature, carefully review this document to make sure the
information outlined is consistent with your knowledge of the prior impairment.
I, the undersigned employer representative, hereby provide the above
information under oath.
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INSTRUCTIONS
1. The
affiant must be someone who has firsthand knowledge of the worker's
pre-existing condition such as an individual in an executive, personnel, or
personnel-advisory capacity, or, if an employer is subject to the Americans
With Disabilities Act, the designated custodian of (medical) records.
2. Attach any documentation or records that
were in the employer's possession prior to the subsequent injury. If you attach
documents, these must be accompanied by certification on employer's letterhead
that said documents were contained in the employer's files. Any reports
specifically referred to in the affidavit must be attached and
certified.
3. The employer should
identify the actual date of knowledge of the prior impairment.
4. The employer, if possible, should list any
individuals either currently or formerly working for the employer who may have
firsthand knowledge of the employee's pre-existing disability.
a. _____________ ________________
_______________
Name Address Telephone No.
b. _____________ ________________
_______________
Name Address Telephone No.
c. _____________ ________________
_______________
Name Address Telephone No.
Notes
Ga. Comp. R. & Regs. R. 622-1-.05
O.C.G.A. Sec.
34-9-354.
Original Rule entitled
"Employer's Knowledge Statement" adopted. F. May 26, 1987; eff. June 15, 1987.
Repealed: New
Rule of same title adopted. F. Sept. 9, 1993; eff. Sept. 29, 1993.
Amended: F.
Mar. 18, 2002; eff.
Apr. 7, 2002.
