Tennessee First Report PDF Details

Understanding the critical aspects of the Tennessee First Report form is essential for employers and employees navigating the aftermath of a workplace injury or illness. This form, mandated by the Tennessee Workers' Compensation Law, serves as the initial notification of a workplace injury or illness, facilitating the claims process for workers' compensation benefits. Employers are required to complete and file this form with their insurance carrier promptly upon notification of an injury or illness. The form captures detailed information including the type of claim, pertinent dates such as the injury date and the date the employer was notified, employee and employer details, as well as specifics about the injury or illness—nature, cause, and body part affected. It also outlines the expectations for both employers and employees regarding the provision of false information, which can lead to serious penalties, including fines and imprisonment. The Tennessee Department of Labor and Workforce Development has established a Benefit Review System to assist and provide guidance through this process, underscoring the state's commitment to supporting workers during challenging times. This comprehensive approach ensures that the rights and well-being of employees are safeguarded while providing a clear framework for employers to follow in the event of a workplace incident.

QuestionAnswer
Form NameTennessee First Report
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesfirst report work, tennessee department of labor forms employers first report of injury, tennessee first report of injury form, tennessee first report

Form Preview Example

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

EMPLOYER’S FIRST REPORT OF WORK INJURY OR ILLNESS

 

JURISDICTION CLAIM # (STATE FILE #)

 

 

 

CLAIM TYPE CODE

 

THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE

 

 

 

 

 

 

 

 

 

 

 

 

MED ONLY

 

 

TENNESSEE

WORKERS'

 

COMPENSATION

LAW

AND

MUST

BE

 

 

 

 

 

 

 

 

 

 

 

 

INDEMNITY

 

 

 

 

CLAIMS ADM CLAIM # (INSURER CLAIM #)

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETED

AND

FILED WITH

YOUR

 

 

INSURANCE

CARRIER

 

 

 

 

 

 

 

 

 

 

 

 

BECAME LOST TIME

 

 

 

CARRIER

 

 

 

 

 

 

 

 

 

 

 

 

IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR

 

 

 

 

 

 

 

 

 

 

 

TRANSFER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BECAME MED ONLY

 

IMMEDIATELY AFTER NOTICE OF INJURY.

 

 

 

 

 

 

 

OSHA LOG CASE #

 

 

 

 

 

 

 

NOTIFY ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MISLEADING INFORMATION TO ANY PARTY TO A WORKERS'

ADM

NAME OF INSURANCE CARRIER

 

 

 

 

 

 

CARRIER FEIN

 

 

COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FRAUD.

PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF

CLAIMS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE BENEFITS.

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIMS ADMIN FIRM NAME (IF DIFFERENT FROM

 

 

 

FEIN OF CLMS ADM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF YOU HAVE QUESTIONS, THE STATE NOW HAS A BENEFIT REVIEW

 

 

 

 

 

 

CARRIER)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SYSTEM

WHERE A

WORKERS' COMPENSATION

SPECIALIST

CAN

 

CLAIMS ADJUSTER NAME

 

 

 

 

 

 

CLMS ADJ PHONE #

 

 

 

 

 

 

 

 

 

PROVIDE ASSISTANCE. CALL 1-800-332-2667 (TDD).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIM HANDLING OFFICE ADDRESS LINE 1 AND LINE 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER NAME

 

 

 

 

 

 

EMPLOYER FEIN

 

 

SIC CODE

 

 

 

 

 

 

 

PHONE NUMBER

 

 

MPLOYERE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

STATE

ZIP

 

 

INSURED REPORT #

EMPLOYER LOCATION

 

 

EMPLOYER ADDRESS LINE 1 AND LINE 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATURE OF BUSINESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICY

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

 

GENDER

 

 

 

 

 

 

 

PIECE WORKER

 

 

 

 

 

 

 

EMPLOYEE LAST NAME

 

 

 

 

 

 

PHONE INCL AREA CODE

 

 

 

 

 

 

 

 

SEASONAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MALE

 

 

 

 

 

 

 

VOLUNTEER

 

 

 

 

 

 

 

FIRST

 

 

 

 

 

 

MI

 

DEPARTMENT REGULARLY

 

FEMALE

 

 

 

 

 

APPRENTICE FULL TIME

 

 

 

EMPLOYEE

 

 

 

 

 

 

 

 

 

 

WORKED

 

 

UNKNOWN

 

 

 

APPRENTICE PART TIME

 

 

 

ADRRESS LINE 1 & 2

 

 

 

 

 

 

 

 

 

 

 

 

OCCUPATION DESCRIPTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

STATE

ZIP

 

 

MARITAL STATUS

 

 

 

 

MARRIED

 

 

NCCI CLASS CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNMARRIED, SINGLE,

 

 

SEPARATED

 

 

 

 

 

 

 

SSN

 

 

 

 

DATE OF BIRTH

 

 

DATE OF HIRE

 

DIVORCED

 

 

 

 

UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WAGE

WAGE

 

PERIOD

WEEKLY

 

NUMBER OF DAYS WORKED PER

 

SALARY 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE CLAIM ADM NOTIFIED OF INJURY

 

HOW INJURY OR ILLNESS OCCURRED.

DESCRIBE THE INCIDENT INCLUDING WHAT THE EMPLOYEE WAS DOING

 

 

 

 

 

 

 

 

 

JUST BEFORE, THE PART OF THE BODY AFFECTED AND HOW, AND OBJECT OR SUBSTANCE THAT DIRECTLY

INJURY

DATE LAST DAY WORKED

 

 

 

 

HARMED THE EMPLOYEE.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE DISABILITY BEGAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCIDENT/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RETURN TO WORK DATE (IF APPLICABLE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF DEATH CLAIM, GIVE #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF DEATH (IF APPLICABLE)

 

 

 

DEPENDENTS FOR EACH RELATIONSHIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WIDOW

 

 

 

FATHER

 

____ SISTER

 

 

 

 

 

 

 

TOTAL # DEPENDENTS

 

 

 

 

 

 

WIDOWER

 

 

____ DAUGHTER

 

____ BROTHER

 

 

 

 

 

 

 

 

 

DID INJURY/ILLNESS OCCUR ON EMPLOYERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREMISES?

YES NO

 

 

 

 

 

MOTHER

 

 

____ SON

 

____ HANDICAPPED CHILD

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS WHERE INJURY

OCCURRED (IF OTHER THAN EMPLOYERS PREMISES)

 

 

 

 

 

 

 

 

 

 

 

COUNTY OF INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

STATE

 

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN NAME

 

 

 

 

 

 

 

 

 

 

 

 

HOSPITAL OR OFF SITE TREATMENT NAME

 

 

 

TREATMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS LINE 1 AND 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS LINE 1 AND 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

STATE

 

ZIP

 

CITY

 

 

 

 

 

 

 

 

 

 

STATE

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INITIAL TREATMENT

 

 

MINOR BY EMPLOYER

 

 

HOSPITALIZED > 24 HRS

 

 

 

 

 

 

FUTURE MAJOR MEDICAL/LOST TIME

 

 

NO MEDICAL TREATMENT

 

 

MINOR BY CLINIC/HOSPITAL

EMERGENCY CARE

 

 

 

 

 

 

ANTICIPATED

 

 

 

 

 

 

OTHER

DATE PREPARED

 

PREPARERS NAME & TITLE

 

PREPARERS COMPANY NAME

 

 

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LB-0021 (REV. 12/07)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RDA 10183

How to Edit Tennessee First Report Online for Free

We have applied the efforts of the best software engineers to make the PDF editor you can benefit from. The app will let you fill out the tennessee first work document effortlessly and don’t waste time. Everything you need to undertake is adhere to the following simple instructions.

Step 1: The initial step would be to choose the orange "Get Form Now" button.

Step 2: You can now modify the tennessee first work. You need to use the multifunctional toolbar to add, delete, and change the text of the document.

Complete the tennessee first work PDF by entering the content needed for every single section.

filling out tennessee first report of injury form step 1

Write down the essential details in WAGE, PERIOD, HOURLY DAILY, WEEKLY BIWEEKLY MONTHLY, NUMBER OF DAYS WORKED PER WEEK, SALARY CONTINUED IN LIEU OF, YES, FULL WAGES PAID FOR DATE OF INJURY, YES, DATE OF INJURY, TIME OF INJURY COULD NOT BE, TIME EMPLOYEE BEGAN WORK ON INJURY, DATE EMPLOYER NOTIFIED OF INJURY, BODY PART AFFECTED CODE, and NATURE OF INJURY CODE area.

Filling in tennessee first report of injury form step 2

The software will request particulars to automatically prepare the section INITIAL TREATMENT, NO MEDICAL TREATMENT, MINOR BY EMPLOYER MINOR BY, HOSPITALIZED HRS EMERGENCY CARE, FUTURE MAJOR MEDICALLOST TIME, ANTICIPATED, T N E M T A E R T, DATE PREPARED R E H T O, LB REV, PREPARERS NAME TITLE, PREPARERS COMPANY NAME, PHONE NUMBER, and RDA.

Finishing tennessee first report of injury form stage 3

Step 3: Choose the "Done" button. Now you may upload the PDF form to your electronic device. As well as that, you may send it through electronic mail.

Step 4: Generate copies of the file - it can help you stay away from potential future difficulties. And don't be concerned - we are not meant to disclose or check the information you have.

Watch Tennessee First Report Video Instruction

Please rate Tennessee First Report

1 Votes
If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .