Free FORM C-23 - Tennessee

FORM C-23 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002

NOTICE OF DENIAL OF CLAIM FOR 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 of Disability ___________________

1. Date compensation was denied: ___________________________________________________ 2. Date claimant was notified of denial: ______________________________________________ 3. Date doctors were notified of denial: _______________________________________________ State basis for denial of compensation: _______________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _____________________________________
Insurer/Self Insurer ____________________________________________ Address ____________________________________________ Address

_____________________________________
Phone/Fax/Email of Sender

Date ________________________________
LB-0283 (REV. 12/07)
RDA 10183