Report An Injury Contact Form printable pdf download

TENNESSEE WORKERS’ COMPENSATION INSURANCE POSTING NOTICE

The law requires this notice to be posted at the employer’s place of business so all employees have access to it.

WHICH EMPLOYERS ARE COVERED BY THE TENNESSEE WORKERS’ COMPENSATION ACT?

All employers with five (5) or more full or part-time employees, except as indicated below.

All employers engaged in the mining and production of coal with one (1) or more employees.

All workers in the construction industry unless they are specifically exempted.

WHAT SHOULD AN EMPLOYEE DO IF INJURED AT WORK?

1 . Report the injury to the employer immediately;

2. Select a treating physician from a panel provided by the employer on the form described

below. To report an injury contact:

___________________________________________________________________________________________________________________

Name of employer representative to notify in event of a work related injury

___________________________________________________________________________________________________________________

Telephone number of employer representative to notify in event of a work related injury

____________________________________________________________________________________________________________

Address of employer representative to notify in event of a work related injury

3. If you have questions or problems, contact the Bureau as indicated below.

WHAT SHOULD AN EMPLOYER DO WHEN AN INJURY IS REPORTED?

1. Immediately complete a First Report of Work Injury form and send it to the workers’ compensation insurance

company or the third party administrator;

AND,

2. Offer the employee a panel of physicians. The physicians must be provided on the official state form, which is

the “AGREEMENT BETWEEN EMPLOYER/EMPLOYEE CHOICE OF PHYSICIAN —Form C-42.”

Additional instructions are available on the form. The form is available at:

The Tennessee Bureau of Workers’ Compensation has staff available to help both employees and employers.

For more information contact:

TENNESSEE BUREAU OF WORKERS’ COMPENSATION

220 FRENCH LANDING DRIVE, 1-B

NASHVILLE, TENNESSEE 37243-1002

615-532-4812 OR TOLL FREE 800-332-2667

800-332-2257 (TDD)

LB-0922 (REV. 7/15)

Authorization No. 337545

10183

RDA

Report An Injury Contact Form