Request For Assistance Form C40a
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1
2FORM C40A
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers’ Compensation
2222 Rosa L. Parks Blvd.
Nashville, Tennessee 37228
RFA NUMBER
Toll Free: 1-800-332-2667
FAX: 615-253-1223 or 615-253-2479
STATE FILE NUMBER
REQUEST FOR ASSISTANCE
Failure To Complete All Items On This Form Will Cause Delay In Processing And May Result In The Form
Being Returned To The Requesting Party. For assistance in completing this form call 1-800-332-2667.
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.
A) DATE OF INJURY:
________________________________________
B) ASSISTANCE IS REQUESTED FOR: (Check all that apply)
Temporary Disability Benefits: ___________ Medical Care Benefits: _______________
Penalty for late payment or non-payment of benefits: ________ Discovery:
C) INJURED EMPLOYEE’S NAME:
_____________________________________________________
SSN: _____________________________ Date of Birth: _________________________
Street Address: ___________________________________________________________
City: ______________________________ State: __________ Zip: _________________
County:____________________________ Phone: ______________________________
Email Address: ___________________________________________________________
Is Employee Represented By An Attorney? _____________________________________
Attorney’s Name: _________________________________________________________
Mailing Address: __________________________________________________________
Telephone: ________________________ Fax: _________________________________
Email Address: ___________________________________________________________
D) EMPLOYER’S NAME:______________________________________________________
Street Address: ___________________________________________________________
City: ______________________________ State: __________ Zip: _________________
County: ___________________________ Telephone: ___________________________
Email Address: ___________________________________________________________
Is Employer Represented By An Attorney? _____________________________________
Attorney’s Name: _________________________________________________________
Mailing Address: __________________________________________________________
Telephone: ________________________ Fax: _________________________________
Email Address: ___________________________________________________________
Do Five Or More Employees Work For Employer? ________________________________
LB-0381 (REV. 04/09)
Pg 1 of 2
RDA 10183
American LegalNet, Inc.
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