Free APPENDIX A - Tennessee

FORM C-29 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002

FINAL REPORT OF PAYMENT AND RECEIPT 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 #: Employee First Name: Address: City: Employer's Name (doing business as): Business Address: City: Insurance Co/Claim Handler Name: Insurance Co/Claim Handler Address: City: Date of Injury: Total # of days lost: State: Zip: First date out of work: Date physician returned claimant Maximum Improvement to work: Date: Wages changed? No Returned to: Same Employer or Yes If yes, New Employer From $ to $ Average Weekly Wage: $ Weekly Compensation Rate: $ State: Insurer File #: Zip: State: FEIN: Zip: Social Security #: MI Last:

Date of Birth:

Compensation payments were made on the following basis: Temporary Total Amount: Permanent Partial Amount: Permanent Partial based on: Death Benefit Amount: Total Medical Paid to Date: $ $ $ $ weeks days Temporary Partial Amount: Permanent Total Amount: Permanent Total based on: Funeral Expenses: Employees legal fees: $ $ $ $ weeks, days

Was salary paid in lieu of comp? Yes No Employers/Ins Co. legal fees: $ Mark appropriate box of payments listed above that was paid in lump sum. List date paid under type: Temp Partial Permanent Partial Permanent Total Death Benefits Temp. Total
State Physicians % rating and scheduled body part: Payments based on (% rate and scheduled body part):

I certify by signing that I have received Workers' Compensation benefit amounts as itemized above. I understand that this is not a release. ________________________________________________________________ Employee's Signature

____________________________________________________________________
Position ______________________
RDA 10183

Reason the injured employee did not sign this report: _______________________________________________ Insurance Carrier Representative
LB-0020 (REV.12/07)