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Notice Of Lawsuit C-28 - Tennessee

Notice Of Lawsuit Form. This is a Tennessee form and can be used in Workers Compensation .
 Fillable pdf Last Modified 1/25/2008
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C-28 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers Compensation Nashville, Tennessee 37243-0661 NOTICE OF LAWSUITIt is a crime to knowingly provide false, incomplete or misleading information to any party to a workerscompensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial ofinsurance benefits. State File #: ________________________________ Soc Sec # ________________________________________Employer ________________________________Claimant _________________________________________ Address _________________________________Address _________________________________________ FEIN # _________________________________Insurer __________________________________________ Insurer Claim# ___________________________Date of Injury _____________________________________ Date of Disability __________________________________________________________________________________hereby notifies the Tennessee Workers Petitioner Compensation Division of filing of lawsuit in the captioned claim.Matters in dispute: ____________________________________________________________________________________________________________________________________________________________________________Date lawsuit filed: _______________________________________________________________________________County and Court of filing: ________________________________________________________________________Docket #: ______________________________________________________________________________________Attorney Filing and Firm Name: ____________________________________________________________________ Name __________________________________________________________ Address __________________________________________________________ AddressDated this ________ day of ____________________________, 20 ________. A COPY OF LAWSUIT MUST ACCOMPANY THIS FORMLB-0284 (rev. 8/99)
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