Rule 622-1-.05 - Employer's Knowledge StatementThe 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.
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Repealed: New Rule of same title adopted.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.