FORM C-26 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002
NOTICE OF CHANGE OR TERMINATION OF COMPENSATION BENEFITS 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 #: _________________________ Claimant ________________________________ Employer ________________________________ Social Security # ____________________ FEIN # ___________________________
Employer Address _______________________________________________________________ Insurer __________________________________ Insurer Address Insurer Claim# _____________________
________________________________________________________________ Date of Disability ___________________
Date of Injury _____________________________
CHANGE OF BENEFITS Compensation benefit rate changed from to
Reason for change: _______________________________________________________________ Date of change: __________________________________________________________________
TERMINATION OF BENEFITS
Compensation benefits terminated on ________________________________________________ Reason for termination:____________________________________________________________ _______________________________________________________________________________ Date claimant notified: ____________________________________________________________ ___________________________________
Insurer/Self Insurer
___________________________________
Address _________________________________________ Address
Date _______________________________
LB-0285 (REV. 12/07)
RDA 10183