Tennessee Department Of Labor And Workforce Development Employer'S First Report Of Work Injury Or Illness
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1TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
EMPLOYER’S FIRST REPORT OF WORK INJURY OR ILLNESS
# (
#)
JURISDICTION CLAIM
STATE FILE
CLAIM TYPE CODE
T
HE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE
MED ONLY
T
W
' C
L
ENNESSEE
ORKERS
OMPENSATION
AW
AND
MUST
BE
INDEMNITY
# (
#)
CLAIMS ADM CLAIM
INSURER CLAIM
COMPLETED
AND
FILED
WITH
YOUR
INSURANCE
CARRIER
BECAME LOST TIME
.
BECAME MED ONLY
IMMEDIATELY AFTER NOTICE OF INJURY
#
OSHA LOG CASE
NOTIFY ONLY
I
,
T IS A CRIME TO KNOWINGLY PROVIDE FALSE
INCOMPLETE OR
TRANSFER
'
MISLEADING
INFORMATION
TO
ANY
PARTY
TO
A
WORKERS
COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING
NAME OF INSURANCE CARRIER
CARRIER FEIN
. P
,
FRAUD
ENALTIES INCLUDE IMPRISONMENT
FINES AND DENIAL OF
.
INSURANCE BENEFITS
(
CLAIMS ADMIN FIRM NAME
IF DIFFERENT FROM
FEIN OF CLMS ADM
I
,
F YOU HAVE QUESTIONS
THE STATE NOW HAS A BENEFIT REVIEW
)
CARRIER
W
' C
S
SYSTEM WHERE A
ORKERS
OMPENSATION
PECIALIST CAN
#
CLAIMS ADJUSTER NAME
CLMS ADJ PHONE
. C
1-800-332-2667 (TDD).
PROVIDE ASSISTANCE
ALL
1
2
CITY
CLAIM HANDLING OFFICE ADDRESS LINE
AND LINE
STATE
ZIP
EMPLOYER NAME
EMPLOYER FEIN
SIC CODE
PHONE NUMBER
1
2
EMPLOYER ADDRESS LINE
AND LINE
NATURE OF BUSINESS
#
CITY
STATE
ZIP
INSURED REPORT
EMPLOYER LOCATION
(
.
INSURED NAME
PARENT CO
IF DIFFERENT THAN
POLICY NUMBER
EFF DATE
EMPLOYMENT STATUS CODE
)
/
EMPLOYER
FULL TIME
REGULAR
?
SELF INSURED
EXP DATE
PART TIME
YES
NO
PIECE WORKER
E
G
MPLOYEE LAST NAME
PHONE INCL AREA CODE
ENDER
SEASONAL
MALE
VOLUNTEER
FEMALE
APPRENTICE FULL TIME
FIRST
MI
DEPARTMENT REGULARLY
UNKNOWN
APPRENTICE PART TIME
WORKED
1 & 2
ADRRESS LINE
OCCUPATION DESCRIPTION
CITY
STATE
ZIP
MARITAL STATUS
MARRIED
NCCI CLASS CODE
,
,
UNMARRIED
SINGLE
SEPARATED
DIVORCED
UNKNOWN
SSN
DATE OF BIRTH
DATE OF HIRE
S
WAGE
PERIOD
WEEKLY
NUMBER OF DAYS WORKED PER
ALARY CONTINUED IN LIEU OF COMPENSATION
YES
NO
$
-
HOURLY
BI
WEEKLY
WEEK
FULL WAGES PAID FOR DATE OF INJURY
YES
NO
DAILY
MONTHLY
DATE OF INJURY
TIME OF INJURY
AM
PM
TIME EMPLOYEE BEGAN WORK ON INJURY DATE
COULD NOT BE DETERMINED
AM
PM
DATE EMPLOYER NOTIFIED OF INJURY
BODY PART AFFECTED CODE
NATURE OF INJURY CODE
CAUSE OF INJURY CODE
H
. D
DATE CLAIM ADM NOTIFIED OF INJURY
OW INJURY OR ILLNESS OCCURRED
ESCRIBE THE INCIDENT INCLUDING WHAT THE EMPLOYEE WAS DOING
,
,
JUST BEFORE
THE PART OF THE BODY AFFECTED AND HOW
AND OBJECT OR SUBSTANCE THAT DIRECTLY
.
HARMED THE EMPLOYEE
DATE LAST DAY WORKED
DATE DISABILITY BEGAN
(
)
RETURN TO WORK DATE
IF APPLICABLE
(
)
,
#
DATE OF DEATH
IF APPLICABLE
IF DEATH CLAIM
GIVE
DEPENDENTS FOR EACH RELATIONSHIP
____
#
WIDOW
FATHER
SISTER
TOTAL
DEPENDENTS
____
____
WIDOWER
DAUGHTER
BROTHER
/
’
DID INJURY
ILLNESS OCCUR ON EMPLOYER
S
____
____
MOTHER
SON
HANDICAPPED CHILD
?
PREMISES
YES
NO
(
’
)
C
ADDRESS WHERE INJURY OCCURRED
IF OTHER THAN EMPLOYER
S PREMISES
OUNTY OF INJURY
CITY
STATE
ZIP
PHYSICIAN NAME
HOSPITAL OR OFF SITE TREATMENT NAME
1
2
1
2
ADDRESS LINE
AND
ADDRESS LINE
AND
CITY
STATE
ZIP
CITY
STATE
ZIP
> 24
/
INITIAL TREATMENT
MINOR BY EMPLOYER
HOSPITALIZED
HRS
FUTURE MAJOR MEDICAL
LOST TIME
/
NO MEDICAL TREATMENT
MINOR BY CLINIC
HOSPITAL
EMERGENCY CARE
ANTICIPATED
’
&
’
DATE PREPARED
PREPARER
S NAME
TITLE
PREPARER
S COMPANY NAME
PHONE NUMBER
-0021 (
. 12/07)
10183
LB
REV
RDA
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