Tennessee > Workers Compensation
Monthly Report Of Non Compensable Injuries Or Diseases C-21 - Tennessee
| Monthly Report Of Non Compensable Injuries Or Diseases Form. This is a Tennessee form and can be used in Workers Compensation . |
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C-21 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers Compensation Nashville, Tennessee 37243-0661 MONTHLY REPORT OF NON-COMPENSABLE INJURIES OR DISEASES INSTRUCTIONS It is a crime to knowingly provide false, incomplete or misleading information to any party toaworkers compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits. This report should include all claims closed in the previous month that resulted in lost time of seven days or less and/orincurred medical expenses. The report should be filed with this division by the fifteenth day of the month, covering theprevious month. This report must contain the total medical expenses paid when closing out the claim. Fatality claims, claims involving more than eight days lost time, or claims resulting in permanent disability must bereported on Form C-20 First Report of Injury. INSURANCE CARRIER NAME ____________________________________________________ INSURANCE CARRIER ADDRESS_________________________________________________ REPORT FOR THE MONTH OF______________________ IN THE YEAR________________ CLAIMS OFFICE FILING THIS REPORT______________________________________________ EMPLOYEE NAME DATE OF EMPLOYER NAME & FEDERAL ID NUMBERNATURE OF DAYS MEDICAL ACCIDENT INJURY LOST EXPENSE1. NUMBER OF CASES WITHOUT LOSS TIME FROM WORK ____________ 2. MEDICAL EXPENSE OF CASES WITHOUT LOSS TIME FROM WORK $ ___________ 3. NUMBER OF CASES WITH ONE TO SEVEN DAYS LOST FROM WORK ____________ 4. TOTAL NUMBER OF LOST WORK DAYS (CUMULATIVE OF #3) ____________ 5. MEDICAL EXPENSE WITH ONE TO SEVEN DAYS LOST FROM WORK $ ___________ TOTAL NUMBER OF CASES FROM LINES 1 AND 3 ____________ LB-0027 (rev. 8/99) TOTAL MEDICAL EXPENSE FROM LINES 2 AND 5 $ ___________
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