Free APPENDIX A - Tennessee

FORM C-26 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002

NOTICE OF CHANGE OR TERMINATION OF COMPENSATION BENEFITS 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 Address Insurer Claim# _____________________

________________________________________________________________ Date of Disability ___________________

Date of Injury _____________________________

CHANGE OF BENEFITS Compensation benefit rate changed from to

Reason for change: _______________________________________________________________ Date of change: __________________________________________________________________
TERMINATION OF BENEFITS

Compensation benefits terminated on ________________________________________________ Reason for termination:____________________________________________________________ _______________________________________________________________________________ Date claimant notified: ____________________________________________________________ ___________________________________
Insurer/Self Insurer

___________________________________
Address _________________________________________ Address

Date _______________________________
LB-0285 (REV. 12/07)
RDA 10183