Free APPENDIX A - Tennessee

FORM C-41 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002

WAGE STATEMENT
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. Employee:__________________________ SSN: Insurer Claim #: _____________________ State File # _______________________ Date of Injury ______________________________

In order to determine the correct rate of compensation to be paid to the above injured party, please fill in the schedule below and return it promptly. This information is required by law and no agreement for payment of compensation can be made until it has been received. Please complete 52 weeks prior to date of accident. Please describe allowances of any character made in lieu of wages that must be deemed a part of employee's earnings: _______________________________________________________________ If the average weekly wage is not based on fifty-two weeks of earnings proceeding the date of injury, please show your computation below: _________________________________________________
WEEK NO. DAYS WEEK ENDING GROSS WAGES WEEK NO. DAYS WEEK ENDING GROSS WAGES

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 TOTAL PAID

Rate per Day _______________ Rate per Hour_____________ Average per Week _________________
I hereby certify that the above is a true and correct account, as taken from our time books or payroll records, of the wages paid to the above-named injured employee for the periods indicated.

Date ______________ 20____ Employer ______________________________________________ Name of Preparer & Title _________________________________________________________________ Phone, Fax, Email _____________________________________________________________________
LB-0384 (REV. 01/08) RDA 10183