Tennessee > Workers Compensation
Notice Of First Payment Of Compensation C-22 - Tennessee
| Notice Of First Payment Of Compensation Form. This is a Tennessee form and can be used in Workers Compensation . |
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C-22 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers Compensation Nashville, Tennessee 37243-0661 NOTICE OF FIRST PAYMENT OF 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 __________________________ (mailed) Date of First Payment (delivered)_________________________Amount of Payment________________________Compensation Payment From_________________________ To ______________________________________Average Weekly Wage ______________________________ Weekly Compensation Rate __________________Check Appropriate Box Temporary Total Disability Benefits Temporary Partial Disability Benefits Permanent Partial Disability Benefits Permanent Total Disability Benefits Death Benefits This notice serves as certification of payment of workers compensation benefits as above stated.______________________________________________________________________________________________ Insurer/Self Insurer/Claim Handler______________________________________________________________________________________________ Address ______________________________________________________________________________________________ Address _______________________________________________________________________ Date LB-0024 (rev. 8/99)
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