Tennessee First Report – Fill Out and Use This PDF

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

BECAME MED ONLY

IMMEDIATELY AFTER NOTICE OF INJURY.

OSHA LOG CASE #

NOTIFY ONLY

IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR

TRANSFER

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)

WORKERS'

COMPENSATION

SPECIALIST

SYSTEM

WHERE A

CAN

CLAIMS ADJUSTER NAME

CLMS ADJ PHONE #

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

CLAIM HANDLING OFFICE ADDRESS LINE 1 AND LINE 2

CITY

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

PIECE WORKER

EMPLOYEE LAST NAME

PHONE INCL AREA CODE

GENDER

SEASONAL

MALE

VOLUNTEER

FEMALE

APPRENTICE FULL TIME

FIRST

MI

DEPARTMENT REGULARLY

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)

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

PREMISES?

YES NO

MOTHER

____ SON

____ HANDICAPPED CHILD

ADDRESS WHERE INJURY OCCURRED (IF OTHER THAN EMPLOYER’S 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

PREPARER’S NAME & TITLE

PREPARER’S COMPANY NAME

PHONE NUMBER

LB-0021 (REV. 12/07)

RDA 10183