Free APPENDIX A - Tennessee

FORM C-27 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002

NOTICE OF CONTROVERSY

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 __________________ ___________________________________
Insurer/Self Insurer

___________________________________
Address

___________________________________
Address

Notice is hereby given to the Tennessee Workers' Compensation Division of controversy in the captioned workers' compensation claim. Date Compensation benefits stopped ________________________________________________ Matters in dispute _______________________________________________________________ ______________________________________________________________________________ Date claimant notified ____________________________________________________________ ____________________________________
Signature

Dated this __________ day of _____________, 20 ________.
LB-0280 (REV. 12/07)
RDA 10183