Tennessee > Workers Compensation

Notice Of Controversy C-27 - Tennessee

Notice Of Controversy Form. This is a Tennessee form and can be used in Workers Compensation .
 Fillable pdf Last Modified 12/3/2010
Get this form for FREE as a print-only pdf

FORM C-27 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 NOTICE OF CONTROVERSY 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 Claim# ____________________ Insurer Address _________________________________________________________________ Date of Injury _____________________________ Date of Disability __________________ ___________________________________ Insurer/Self Insurer ___________________________________ Address ___________________________________ Address Notice is hereby given to the Tennessee Workers' Compensation Division of controversy in the captioned workers' compensation claim. Date Compensation benefits stopped ________________________________________________ Matters in dispute _______________________________________________________________ ______________________________________________________________________________ Date claimant notified ____________________________________________________________ ____________________________________ Signature Dated this __________ day of _____________, 20 ________. LB-0280 (REV. 12/07) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document
URL
Embed


Popular Searches

  1. Request for entry of default
  2. Preliminary Change of Ownership Report
  3. Decree of Dissolution of Marriage
  4. proof of service of summons
  5. Notice and Acknowledgment of Receipt
  6. fEE WAIVER
  7. Petition to Expunge
  8. writ of replevin
  9. Income and Expense Declaration
  10. divorce forms

Bookmark and Share