FORM C-29 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 FINAL REPORT OF PAYMENT AND RECEIPT OF COMPENSATION It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits State File #: Social Security #: Employee First Name: MI Last: Address: City: State: Employer's Name (doing business as): Zip: FEIN: Business Address: City: State: Insurance Co/Claim Handler Name: Zip: Insurer File #: Insurance Co/Claim Handler Address: City: Date of Injury: State: Zip: First date out of work: Date physician returned claimant Maximum Improvement to work: Date: Wages changed? No Returned to: Same Employer or Yes If yes, New Employer From $ to $ Total # of days lost: Date of Birth: Weekly Compensation Rate: $ Average Weekly Wage: $ Compensation payments were made on the following basis: Temporary Total Amount: $ Temporary Partial Amount: $ Permanent Partial Amount: $ Permanent Total Amount: $ Permanent Partial based on: weeks days Permanent Total based on: weeks, Death Benefit Amount: $ Funeral Expenses: $ Total Medical Paid to Date: $ Employees legal fees: days $ Was salary paid in lieu of comp? Yes No Employers/Ins Co. legal fees: $ Mark appropriate box of payments listed above that was paid in lump sum. List date paid under type: Temp Partial Permanent Partial Permanent Total Death Benefits Temp. Total State Physicians % rating and scheduled body part: Payments based on (% rate and scheduled body part): I certify by signing that I have received Workers' Compensation benefit amounts as itemized above. I understand that this is not a release. ________________________________________________________________ Employee’s Signature ____________________________________________________________________ Reason the injured employee did not sign this report: _______________________________________________ Insurance Carrier Representative LB-0020 (REV.12/07) Position ______________________ RDA 10183 American LegalNet, Inc. www.FormsWorkflow.com