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 #)
OSHA LOG CASE #
CLAIM TYPE CODE
MED ONLY
INDEMNITY
BECAME LOST TIME
BECAME MED ONLY
NOTIFY ONLY
TRANSFER
NAME OF INSURANCE CARRIER CARRIER FEIN
CLAIMS ADMIN FIRM NAME (IF DIFFERENT FROM
CARRIER
)
FEIN OF CLMS ADM
CLAIMS ADJUSTER NAME CLMS ADJ PHONE #
T
HE 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
.
I
T 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
.
I
F 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).
CLAIMS ADM/CARRIER
CLAIM HANDLING OFFICE ADDRESS LINE 1 AND LINE 2
CITY
STATE ZIP
EMPLOYER NAME EMPLOYER FEIN SIC CODE PHONE NUMBER
EMPLOYER ADDRESS LINE 1 AND LINE 2 NATURE OF BUSINESS
E MPLOYER
CITY STATE ZIP INSURED REPORT # EMPLOYER LOCATION
POLICY NUMBER EFF DATE
POLICY
INSURED NAME (PARENT CO. IF DIFFERENT THAN
EMPLOYER
)
SELF INSURED?
YES NO
EXP DATE
EMPLOYEE LAST NAME PHONE INCL AREA CODE
FIRST MI DEPARTMENT REGULARLY
WORKED
G
ENDER
MALE
FEMALE
UNKNOWN
EMPLOYMENT STATUS CODE
FULL TIME/REGULAR
PART TIME
PIECE WORKER
SEASONAL
VOLUNTEER
APPRENTICE FULL TIME
APPRENTICE PART TIME
ADRRESS LINE 1 & 2 OCCUPATION DESCRIPTION
CITY STATE ZIP
EMPLOYEE
SSN DATE OF BIRTH DATE OF HIRE
MARITAL STATUS
UNMARRIED, SINGLE,
DIVORCED
MARRIED
SEPARATED
UNKNOWN
NCCI CLASS CODE
SALARY CONTINUED IN LIEU OF COMPENSATION YES NO
WAGE
WAGE
$
PERIOD
HOURLY
DAILY
WEEKLY
BI-WEEKLY
MONTHLY
NUMBER OF DAYS WORKED PER
WEEK
FULL WAGES PAID FOR DATE OF INJURY YES NO
DATE OF INJURY TIME OF INJURY AM PM
COULD NOT BE DETERMINED
TIME EMPLOYEE BEGAN WORK ON INJURY DATE
AM PM
DATE EMPLOYER NOTIFIED OF INJURY BODY PART AFFECTED CODE NATURE OF INJURY CODE CAUSE OF INJURY CODE
DATE CLAIM ADM NOTIFIED OF INJURY
DATE LAST DAY WORKED
DATE DISABILITY BEGAN
RETURN TO WORK DATE (IF APPLICABLE)
H
OW 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 DATE OF DEATH (IF APPLICABLE)
DID INJURY/ILLNESS OCCUR ON EMPLOYER’S
PREMISES
? YES NO
WIDOW
WIDOWER
MOTHER
FATHER
____
DAUGHTER
____
SON
____
SISTER
____
BROTHER
____
HANDICAPPED CHILD
TOTAL # DEPENDENTS
ADDRESS WHERE INJURY OCCURRED (IF OTHER THAN EMPLOYER’S PREMISES)
ACCIDENT/INJURY
CITY STATE ZIP
C
OUNTY OF INJURY
PHYSICIAN NAME HOSPITAL OR OFF SITE TREATMENT NAME
ADDRESS LINE 1 AND 2 ADDRESS LINE 1 AND 2
CITY STATE ZIP CITY STATE ZIP
TREATMENT
INITIAL TREATMENT
NO MEDICAL TREATMENT
MINOR BY EMPLOYER
MINOR BY CLINIC/HOSPITAL
HOSPITALIZED > 24 HRS
EMERGENCY CARE
FUTURE MAJOR MEDICAL/LOST TIME
ANTICIPATED
OTHER
DATE PREPARED PREPARER’S NAME & TITLE PREPARER’S COMPANY NAME PHONE NUMBER
LB-0021 (REV. 12/07) RDA 10183
