Free APPENDIX A - Tennessee

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT EMPLOYER'S FIRST REPORT OF WORK INJURY OR ILLNESS
JURISDICTION CLAIM # (STATE FILE #) CLAIMS ADM CLAIM # (INSURER CLAIM #) CLAIMS ADM/CARRIER OSHA LOG CASE # CLAIM TYPE CODE MED ONLY INDEMNITY BECAME LOST TIME BECAME MED ONLY NOTIFY ONLY TRANSFER CARRIER FEIN FEIN OF CLMS ADM CLMS ADJ PHONE #

THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE TENNESSEE WORKERS'
COMPLETED AND

COMPENSATION
WITH YOUR

LAW AND
INSURANCE

MUST

BE

FILED

CARRIER

IMMEDIATELY AFTER NOTICE OF INJURY. IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO ANY PARTY TO A WORKERS' COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING FRAUD. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.

NAME OF INSURANCE CARRIER CLAIMS ADMIN FIRM NAME (IF DIFFERENT FROM CARRIER) CLAIMS ADJUSTER NAME CLAIM HANDLING OFFICE ADDRESS LINE 1 AND LINE 2 EMPLOYER NAME

IF YOU HAVE QUESTIONS, THE STATE NOW HAS A BENEFIT REVIEW SYSTEM WHERE A WORKERS' COMPENSATION SPECIALIST CAN PROVIDE ASSISTANCE. CALL 1-800-332-2667 (TDD).
CITY STATE PHONE NUMBER NATURE OF BUSINESS ZIP

EMPLOYER FEIN

SIC CODE

E MPLOYER

EMPLOYER ADDRESS LINE 1 AND LINE 2 CITY INSURED NAME (PARENT CO. IF DIFFERENT THAN EMPLOYER) STATE ZIP POLICY NUMBER SELF INSURED? YES NO

INSURED REPORT # EFF DATE EXP DATE

EMPLOYER LOCATION EMPLOYMENT STATUS CODE FULL TIME/REGULAR PART TIME PIECE WORKER SEASONAL VOLUNTEER APPRENTICE FULL TIME APPRENTICE PART TIME

POLICY

EMPLOYEE LAST NAME
FIRST EMPLOYEE ADRRESS LINE 1 & 2 CITY SSN WAGE WAGE PERIOD HOURLY DAILY STATE DATE OF BIRTH WEEKLY BI-WEEKLY MONTHLY MI

PHONE INCL AREA CODE DEPARTMENT REGULARLY WORKED

GENDER
MALE FEMALE UNKNOWN OCCUPATION DESCRIPTION

ZIP DATE OF HIRE

MARITAL STATUS UNMARRIED, SINGLE, DIVORCED

MARRIED SEPARATED UNKNOWN

NCCI CLASS CODE

$

NUMBER OF DAYS WORKED PER WEEK

SALARY CONTINUED IN LIEU OF COMPENSATION
FULL WAGES PAID FOR DATE OF INJURY AM PM YES

YES NO

NO

DATE OF INJURY DATE EMPLOYER NOTIFIED OF INJURY DATE CLAIM ADM NOTIFIED OF INJURY ACCIDENT/INJURY DATE LAST DAY WORKED DATE DISABILITY BEGAN RETURN TO WORK DATE (IF APPLICABLE) DATE OF DEATH (IF APPLICABLE) DID INJURY/ILLNESS OCCUR ON EMPLOYER'S YES NO PREMISES?

TIME OF INJURY COULD NOT BE DETERMINED BODY PART AFFECTED CODE

TIME EMPLOYEE BEGAN WORK ON INJURY DATE AM PM CAUSE OF INJURY CODE

NATURE OF INJURY CODE

HOW INJURY OR ILLNESS OCCURRED. DESCRIBE THE INCIDENT INCLUDING WHAT THE EMPLOYEE WAS DOING JUST BEFORE, THE PART OF THE BODY AFFECTED AND HOW, AND OBJECT OR SUBSTANCE THAT DIRECTLY HARMED THE EMPLOYEE.

IF DEATH CLAIM, GIVE # DEPENDENTS FOR EACH RELATIONSHIP WIDOW WIDOWER MOTHER FATHER

____ DAUGHTER ____ SON
CITY STATE

____ SISTER ____ BROTHER ____ HANDICAPPED CHILD
ZIP

TOTAL # DEPENDENTS

ADDRESS WHERE INJURY OCCURRED (IF OTHER THAN EMPLOYER'S PREMISES)

COUNTY OF INJURY

PHYSICIAN NAME TREATMENT ADDRESS LINE 1 AND 2 CITY INITIAL TREATMENT NO MEDICAL TREATMENT OTHER DATE PREPARED STATE ZIP CITY

HOSPITAL OR OFF SITE TREATMENT NAME ADDRESS LINE 1 AND 2 STATE ZIP

MINOR BY EMPLOYER MINOR BY CLINIC/HOSPITAL PREPARER'S NAME & TITLE

HOSPITALIZED > 24 HRS EMERGENCY CARE PREPARER'S COMPANY NAME

FUTURE MAJOR MEDICAL/LOST TIME ANTICIPATED PHONE NUMBER

LB-0021 (REV. 12/07)

RDA 10183