Tennessee > Workers Compensation
Notice Of Denial Of Claim For Compensation C-23 - Tennessee
| Notice Of Denial Of Claim For Compensation Form. This is a Tennessee form and can be used in Workers Compensation . |
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C-23 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers Compensation Nashville, Tennessee 37243-0661 NOTICE OF DENIAL OF CLAIM FOR COMPENSATIONIt is a crime to knowingly provide false, incomplete or misleading information to any party to a workers compensation transactionfor the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits.State File # ________________________________ Claimant _________________________________________ Social Security # __________________________Employer ________________________________________ FEIN # _________________________________Insurer __________________________________________ InsurerClaim# ___________________________Date of Injury _____________________________________ Date of Disability __________________________1. Date compensation was denied: __________________________________________________________________2. Date claimant was notified of denial: ______________________________________________________________3. Date doctors were notified of denial:_______________________________________________________________State basis for denial of compensation: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________ Insurer/Self Insurer ____________________________________________ Address ____________________________________________ AddressDate ______________________________________ LB-0283 (rev. 8/99)
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