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
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Tennessee Bureau of Workers' Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 NOTICE OF CONTROVERSY This form can be filed only if: A C-20 First Report of Injury has been filed with this Bureau in this matter; · Temporary disability or medical benefits have been provided to the claimant and, The Employer/Insurer has discovered new information and is terminating those benefits. · · State File Number _____________________ Claimant Name _____________________________________ SSN __________________________________ Date of Injury ____________________________ Date of Disability __________________________________ Employer Name _____________________________________ FEIN _________________________________ Employer Mailing Address ___________________________________________________________________ City _____________________________________ State ________________________ ZIP _______________ Insurer ____________________________________ Insurer Claim # _________________________________ Insurer Mailing Address _____________________________________________________________________ City _____________________________________ State ________________________ ZIP _______________ Date benefits terminated ______________________ Date Claimant was notified ________________________ Basis for termination ________________________________________________________________________ __________________________________________________________________________________________ Notice is hereby given to the Tennessee Bureau of Workers' Compensation of controversy in the abovereferenced workers' compensation claim. Signature ___________________________________________________________ Date __________________ Printed name of submitter ____________________________________________ Phone # _________________ Email _____________________________________________________ Fax # __________________________ LB-0280 (REV3/16) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com
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