TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT EMPLOYER'S FIRST REPORT OF WORK INJURY OR ILLNESS
JURISDICTION CLAIM # (STATE FILE #) CLAIMS ADM CLAIM # (INSURER CLAIM #) CLAIMS ADM/CARRIER OSHA LOG CASE # CLAIM TYPE CODE MED ONLY INDEMNITY BECAME LOST TIME BECAME MED ONLY NOTIFY ONLY TRANSFER CARRIER FEIN FEIN OF CLMS ADM CLMS ADJ PHONE #
THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE TENNESSEE WORKERS'
COMPLETED AND
COMPENSATION
WITH YOUR
LAW AND
INSURANCE
MUST
BE
FILED
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.
NAME OF INSURANCE CARRIER CLAIMS ADMIN FIRM NAME (IF DIFFERENT FROM CARRIER) CLAIMS ADJUSTER NAME CLAIM HANDLING OFFICE ADDRESS LINE 1 AND LINE 2 EMPLOYER NAME
IF YOU HAVE QUESTIONS, THE STATE NOW HAS A BENEFIT REVIEW SYSTEM WHERE A WORKERS' COMPENSATION SPECIALIST CAN PROVIDE ASSISTANCE. CALL 1-800-332-2667 (TDD).
CITY STATE PHONE NUMBER NATURE OF BUSINESS ZIP
EMPLOYER FEIN
SIC CODE
E MPLOYER
EMPLOYER ADDRESS LINE 1 AND LINE 2 CITY INSURED NAME (PARENT CO. IF DIFFERENT THAN EMPLOYER) STATE ZIP POLICY NUMBER SELF INSURED? YES NO
INSURED REPORT # EFF DATE EXP DATE
EMPLOYER LOCATION EMPLOYMENT STATUS CODE FULL TIME/REGULAR PART TIME PIECE WORKER SEASONAL VOLUNTEER APPRENTICE FULL TIME APPRENTICE PART TIME
POLICY
EMPLOYEE LAST NAME
FIRST EMPLOYEE ADRRESS LINE 1 & 2 CITY SSN WAGE WAGE PERIOD HOURLY DAILY STATE DATE OF BIRTH WEEKLY BI-WEEKLY MONTHLY MI
PHONE INCL AREA CODE DEPARTMENT REGULARLY WORKED
GENDER
MALE FEMALE UNKNOWN OCCUPATION DESCRIPTION
ZIP DATE OF HIRE
MARITAL STATUS UNMARRIED, SINGLE, DIVORCED
MARRIED SEPARATED UNKNOWN
NCCI CLASS CODE
$
NUMBER OF DAYS WORKED PER WEEK
SALARY CONTINUED IN LIEU OF COMPENSATION
FULL WAGES PAID FOR DATE OF INJURY AM PM YES
YES NO
NO
DATE OF INJURY DATE EMPLOYER NOTIFIED OF INJURY DATE CLAIM ADM NOTIFIED OF INJURY ACCIDENT/INJURY DATE LAST DAY WORKED DATE DISABILITY BEGAN RETURN TO WORK DATE (IF APPLICABLE) DATE OF DEATH (IF APPLICABLE) DID INJURY/ILLNESS OCCUR ON EMPLOYER'S YES NO PREMISES?
TIME OF INJURY COULD NOT BE DETERMINED BODY PART AFFECTED CODE
TIME EMPLOYEE BEGAN WORK ON INJURY DATE AM PM CAUSE OF INJURY CODE
NATURE OF INJURY CODE
HOW INJURY OR ILLNESS OCCURRED. DESCRIBE THE INCIDENT INCLUDING WHAT THE EMPLOYEE WAS DOING JUST BEFORE, THE PART OF THE BODY AFFECTED AND HOW, AND OBJECT OR SUBSTANCE THAT DIRECTLY HARMED THE EMPLOYEE.
IF DEATH CLAIM, GIVE # DEPENDENTS FOR EACH RELATIONSHIP WIDOW WIDOWER MOTHER FATHER
____ DAUGHTER ____ SON
CITY STATE
____ SISTER ____ BROTHER ____ HANDICAPPED CHILD
ZIP
TOTAL # DEPENDENTS
ADDRESS WHERE INJURY OCCURRED (IF OTHER THAN EMPLOYER'S PREMISES)
COUNTY OF INJURY
PHYSICIAN NAME TREATMENT ADDRESS LINE 1 AND 2 CITY INITIAL TREATMENT NO MEDICAL TREATMENT OTHER DATE PREPARED STATE ZIP CITY
HOSPITAL OR OFF SITE TREATMENT NAME ADDRESS LINE 1 AND 2 STATE ZIP
MINOR BY EMPLOYER MINOR BY CLINIC/HOSPITAL PREPARER'S NAME & TITLE
HOSPITALIZED > 24 HRS EMERGENCY CARE PREPARER'S COMPANY NAME
FUTURE MAJOR MEDICAL/LOST TIME ANTICIPATED PHONE NUMBER
LB-0021 (REV. 12/07)
RDA 10183