Tennessee > Workers Compensation
Employers First Report Of Work Injury Or Illness C-20 - Tennessee
| Employers First Report Of Work Injury Or Illness Form. This is a Tennessee form and can be used in Workers Compensation . |
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TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT C20 EMPLOYERS FIRST REPORT OF WORK INJURY OR ILLNESS JURISDICTION CLAIM # (STATE FILE #) CLAIM TYPE CODE MED ONLY The use of this form is required under the provisions of the Tennessee Workers Com pensation Law and must INDEMNITY CLAMS ADM CLAIM # (INSURER CLAIM #) be com pleted and filed with your insurance carrier BECAME LOST TIME immediately after notice of injury. BECAME MED ONLY OSHA LOG CASE # It is a crime to knowin glyp rovide false, incom plete or NOTIFY ONLY misleadin g information to an yp arty to a workers TRANSFER CARRIER com pensation transaction for the purpose of / NAME OF INSURANCE CARRIER CARRIER FEIN committin g fraud. Penalties include im prisonment, fines and denial of insurance benefits. CLAIMS ADMIN FIRM NAME (if different from carrier)FEIN OF CLMS ADM If you have questions, the state now has a benefit review system where a Workers Compensation CLAIMS ADM CLAIMS ADJUSTER NAME CLMS ADJ PHONE # Specialist can provide assistance. Call 1-800-332-2667 (TDD). 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 MPLOYERCITY STATE ZIP INSURED REPORT NUMBER EMPLOYER LOCATION # INSURED NAME (parent co. if different than employer) POLICY NUMBER EFF DATE EMPLOYMENT STATUS CODE FULL TIME/REGULAR SELF INSURED? EXP DATE PART TIME POLICY YES NO PIECE WORKER EMPLOYEE LAST NAME PHONE INCL AREA CODE GENDER SEASONAL MALE VOLUNTEER FEMALE APPRENTICE FULL TIME FIRST MI DEPARTMENT REGULARLY WORKED UNKNOWN APPRENTICE PART TIME ADRRESS LINE 1 & 2 OCCUPATION DESCRIPTION EMPLOYEECITY STATE ZIP MARITAL STATUS MARRIED NCCI CLASS UNMARRIED, SEPARATED CODE SINGLE, DIVORCED UNKNOWN SSN DATE OF BIRTH DATE OF HIRE WAGE PERIOD WEEKLY NUMBER OF DAYS WORKED PER SALARY CONTINUED IN LIEU OF COMPENSATION YES NO $ HOURLY BI-WEEKLY WEEK FULL WAGES PAID FOR DATE OF INJURY YES NO DAILY MONTHLY WAGE DATE OF INJURY TIME OF INJURY AM PMTIME EMPLOYEE BEGAN WORK ON INJURY DATE COULD NOT BE DETERMINED 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 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. DATE LAST DAY WORKED /INJURYDATE DISABILITY BEGAN RETURN TO WORK DATE (IF APPLICABLE) ACCIDENT DATE OF DEATH (IF APPLICABLE) IF DEATH CLAIM, GIVE # DEPENDENTS FOR EACH RELATIONSHIP WIDOW FATHER ____ SISTER TOTAL # DEPENDENTS DID INJURY/ILLNESS OCCUR ON EMPLOYERS WIDOWER ____ DAUGHTER ____ BROTHER PREMISES? YES NO MOTHER ____ SON ____ HANDICAPPED CHILD ADDRESS WHERE INJURY OCCURRED (if other than employers premises) COUNTY OF INJURY CITY STATE ZIP 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 MINOR BY EMPLOYER HOSPITALIZED > 24 HRS FUTURE MAJOR MEDICAL/LOST TIME NO MEDICAL TREATMENT MINOR BY CLINIC/HOSPITAL EMERGENCY CARE ANTICIPATED DATE PREPARED PREPARERNAME & TITLE PREPARERS COMPANY NAME PHONE NUMBER OTHER LB-0021 (REV12-01)
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