Permanent Total Disability Final Order {C-43}

FORM C-43 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Drive Nashville, Tennessee 37243-1002 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. PERMANENT TOTAL DISABILITY FINAL ORDER (MUST BE FILED WITH WORKERS' COMPENSATION WITHIN 30 DAYS OF ENTRY OF THE FINAL ORDER) Claimant's Name: _______________________________________________________ (Please Print) Address: ________________________________________________________________ ________________________________________________________________ Phone Number: _____________________ Social Security #: _____________________ Date of Injury: ___________________ Date of Birth: ______________________ ______________________ Insurer Claim Number: ______________ State File #: Style of Case: ____________________________________________________________ Court/County: ___________________________________________________________ Final Order Entry Date: _____________ Benefits awarded: (Employer) _________ Docket Number: (%) (Second Injury Fund) __________(%) Employer: ________________________ Insurer: Address: ________________________ Address: _____________________________ ________________________ ______________________________ BPR# ________________ Employer/Carrier/Defense Attorney: __________________ Employee Attorney: _________________________ BPR# ______________________ Submitted by: ____________________________ Date: (Please Print) ______________________ LB- 0988 RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com