|
C-20
Tennessee Employer's First Report of Work Injury
Name
of Insurance carrier:
_____________________
Name / Address of Claims Handling Office:_____________________
City:_____________ State:________ Zip:_______
Phone#:_______________________ |
The
use of this form is required under the provisions of the Tennessee
Workers Compensation Law and must be completed and filed with your
insurance carrier immediately after notice of injury.
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.
If
you have questions, the state now has a benefit review system where
a Tennessee Department of Labor Workers’ Compensation Specialist
can provide assistance. Call 1-800-332-2667 (TDD).
|
EMPLOYER
1. Name: _____________________________
Federal Employer Identification #: _________________
2. Address:_________________________ City:
_________________
State: ________
Zip Code: _______
3. Nature of business: _____________________________________
Phone: _________________________
INJURED EMPLOYEE
4. Name: _________________________________________
Social Security #:______________________
5. Address: ________________________ City:_________________
State: __________
Zip Code: _______
6. Phone #:_______________ Occupation (job
title): ____________________
Department: ___________
7. Age:_______ DOB: __________ Male:
_______ Female: ________
Married: ________
Single:________
8. Number of hours worked per day:________
per week: _______
Number of days per week: ________
9. Wages: per hour:$_________ per day:$_________
per week:$_________
Extra wages :$ _________
DESCRIPTION OF THE INJURY OR OCCUPATIONAL DISEASE
10. Did the injury or exposure occur on the employers
premise?
Yes ____ No ____
If no, give the address of where it occurred: ______________________________
City:____________
State: _____ Zip: ________ Country:
______________
11. Describe what the employee was doing when the
injury or exposure occurred;
list tools, equipment or materials involved:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
12. Describe fully how and why the injury or exposure
occurred:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
13. Describe the injury or exposure in detail,
giving the body part affected ( examples:
amputation of right index finger, fell down injuring
low back, exposed to chemicals
causing breathing problems): ___________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
14. Date of the injury: _____/_____/_____
Hour of day:______ am/pm. Give the
date of the notice of the injury or exposure
to the employer, if different than the
date occurred: _____/_____/_____
15. Was the employee paid in full for the date
of the injury or exposure?
Yes _____ No _____
16. Has employee missed work because of the injury
or exposure on any day after the
date it occurred, including weekends or
regularly scheduled days off?
Yes _____ No _____. If yes, give
date last worked: _____/_____/_____
17. Has employee returned to work? Yes _____
No _____
If yes, give date: _____/_____/_____
Returning wages: Per hour :$__________ Per
day :$__________
Per week :$___________
18. Did employee die? Yes _____ No _____
If yes, give date: _____/_____/_____
Name/address of nearest relative:
__________________________________________________________________
__________________________________________________________________
19. Name/Address of physician: _________________________________________
__________________________________________________________________
20. If hospitalized, name/address of hospital:
________________________________
__________________________________________________________________
Date report written: _____/_____/_____ Prepared
by: ______________
Title/Position: ___________
I certify that the information given in this form
is true, correct, and complete to the best
of my knowledge.
Signature of injured employee: ________________________Date:
_____/_____/____
If employee is unable or refuses to sign, state
reason:
___________________________________________________________________
___________________________________________________________________
LB-0021 (Rev. 02/98) |
DO NOT WRITE IN THIS COLUMN
Carrier# (6)
Country# (3)
Occupation(3)
Industry(4)
Ownership(2)
Nature(3)
Body Part(3)
Type(3)
Source(4)
Agency(4)
Disability(1)
|
[ Back To Claims ]
|
