Free FORM C-22 - Tennessee

FORM C-22 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002

NOTICE OF FIRST PAYMENT OF COMPENSATION 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. State File # __________________________ Claimant _________________________________ Employer _________________________________ Social Security # ___________________ FEIN # ___________________________

Employer Address _______________________________________________________________ Insurer ___________________________________ Insurer Claim# ____________________

Insurer Address _________________________________________________________________ Date of Injury ______________________________ Date First Payment (mailed/delivered) ________________ Compensation Payment From__________________ Average Weekly Wage ______________________ Check Appropriate Box Temporary Total Disability Benefits Temporary Partial Disability Benefits Permanent Partial Disability Benefits Permanent Total Disability Benefits Death Benefits This notice serves as certification of payment of workers' compensation benefits as above stated. _______________________________________________________________________________
Insurer/Self Insurer/Claim Handler

Date of Disability ___________________ Amount of Payment __________________ To _______________________________ Weekly Compensation Rate ___________

_______________________________________________________________________________
Address

_______________________________________________________________________________
Address

_______________________________________________________________________________
Date
LB-0024 (REV. 12/07) RDA10183