TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT EMPLOYER’S FIRST REPORT OF WORK INJURY OR ILLNESS JURISDICTION CLAIM # (STATE FILE #) CLAIM TYPE CODE MED ONLY INDEMNITY BECAME LOST TIME BECAME MED ONLY NOTIFY ONLY TRANSFER CLAIMS ADM/CARRIER CLAIMS ADM CLAIM # (INSURER CLAIM #) OSHA LOG CASE # NAME OF INSURANCE CARRIER AND CITY E MPLOYER POLICY EMPLOYER FEIN CITY STATE INSURED NAME (PARENT CO. IF DIFFERENT THAN EMPLOYER) SIC CODE ZIP PHONE NUMBER INSURED REPORT # ZIP POLICY NUMBER EFF DATE SELF INSURED? YES NO MI GENDER MALE FEMALE UNKNOWN DEPARTMENT REGULARLY WORKED ADRRESS LINE 1 & 2 EMPLOYER LOCATION EMPLOYMENT STATUS CODE FULL TIME/REGULAR PART TIME PIECE WORKER SEASONAL VOLUNTEER APPRENTICE FULL TIME APPRENTICE PART TIME EXP DATE PHONE INCL AREA CODE FIRST EMPLOYEE BE CARRIER NATURE OF BUSINESS EMPLOYEE LAST NAME OCCUPATION DESCRIPTION CITY STATE SSN WAGE MUST INSURANCE STATE EMPLOYER ADDRESS LINE 1 AND LINE 2 WAGE LAW AND YOUR IF YOU HAVE QUESTIONS, THE STATE NOW HAS A BENEFIT REVIEW SYSTEM WHERE A WORKERS' COMPENSATION SPECIALIST CAN PROVIDE ASSISTANCE. CALL 1-800-332-2667 (TDD). CLAIM HANDLING OFFICE ADDRESS LINE 1 AND LINE 2 EMPLOYER NAME WITH COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING FRAUD. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. CLMS ADJ PHONE # $ COMPENSATION FILED IMMEDIATELY AFTER NOTICE OF INJURY. IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO ANY PARTY TO A WORKERS' FEIN OF CLMS ADM CLAIMS ADJUSTER NAME COMPLETED CARRIER FEIN CLAIMS ADMIN FIRM NAME (IF DIFFERENT FROM CARRIER) THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE TENNESSEE WORKERS' DATE OF BIRTH PERIOD HOURLY DAILY WEEKLY BI-WEEKLY MONTHLY ZIP MARITAL STATUS UNMARRIED, SINGLE, DIVORCED DATE OF HIRE MARRIED SEPARATED UNKNOWN NCCI CLASS CODE SALARY CONTINUED IN LIEU OF COMPENSATION NUMBER OF DAYS WORKED PER WEEK FULL WAGES PAID FOR DATE OF INJURY NO TIME OF INJURY COULD NOT BE DETERMINED DATE EMPLOYER NOTIFIED OF INJURY BODY PART AFFECTED CODE DATE CLAIM ADM NOTIFIED OF INJURY ACCIDENT/INJURY PM YES NO DATE 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 HARMED THE EMPLOYEE. DATE LAST DAY WORKED AM YES TIME EMPLOYEE BEGAN WORK ON INJURY DATE AM PM NATURE OF INJURY CODE CAUSE OF INJURY CODE DATE DISABILITY BEGAN RETURN TO WORK DATE (IF APPLICABLE) DATE OF DEATH (IF APPLICABLE) IF DEATH CLAIM, GIVE # DEPENDENTS FOR EACH RELATIONSHIP DID INJURY/ILLNESS OCCUR ON EMPLOYER’S YES NO PREMISES? WIDOW WIDOWER MOTHER FATHER ____ DAUGHTER ____ SON ____ SISTER ____ BROTHER ____ HANDICAPPED CHILD COUNTY OF INJURY ADDRESS WHERE INJURY OCCURRED (IF OTHER THAN EMPLOYER’S PREMISES) CITY STATE TREATMENT PHYSICIAN NAME OTHER INITIAL TREATMENT NO MEDICAL TREATMENT DATE PREPARED LB-0021 (REV. 12/07) ZIP HOSPITAL OR OFF SITE TREATMENT NAME ADDRESS LINE 1 AND 2 CITY TOTAL # DEPENDENTS ADDRESS LINE 1 AND 2 STATE ZIP MINOR BY EMPLOYER MINOR BY CLINIC/HOSPITAL PREPARER’S NAME & TITLE CITY HOSPITALIZED > 24 HRS EMERGENCY CARE PREPARER’S COMPANY NAME STATE ZIP FUTURE MAJOR MEDICAL/LOST TIME ANTICIPATED PHONE NUMBER RDA 10183 American LegalNet, Inc. www.FormsWorkflow.com