Free APPENDIX A - Tennessee

FORM C-28 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002

NOTICE OF LAWSUIT 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 #: ______________________________ Soc Sec # ________________________________ Claimant _________________________________ Address __________________________________ Insurer ___________________________________ Employer _________________________ Address __________________________ FEIN # __________________________ Insurer Claim# ____________________

Insurer Address _________________________________________________________________ Date of Injury _____________________________ Date of Disability __________________

Petitioner ___________________________________ hereby notifies the Tennessee Workers'
Compensation Division of filing of lawsuit in the captioned claim.

Matters in dispute: _______________________________________________________________ ______________________________________________________________________________ Date lawsuit filed: _______________________________________________________________ County and Court of filing: ________________________________________________________ Docket #: ______________________________________________________________________ Attorney Filing and Firm Name: ____________________________________________________
Name

________________________________________________
Address

________________________________________________
Address

Dated this ________ day of ____________________________, 20 ________. A COPY OF LAWSUIT MUST ACCOMPANY THIS FORM
LB-0284 (REV. 12/07)
RDA 10183