Tennessee Bureau of Workers' Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM C-23 NOTICE OF DENIAL OF CLAIM FOR COMPENSATION This form can be filed only if: · A C-20 First Report of Injury has been filed with this Bureau in this matter; and, · No temporary disability or medical benefits have been provided to the claimant. State File # ______________________ Claimant Name ____________________________________________ Date of Injury _________________ Date of Disability ________________ SSN _________________________ Employer _______________________________________________________ FEIN _____________________ Business Mailing Address ____________________________________________________________________ City, State, ZIP _____________________________________________________________________________ Insurer ______________________________________________Ins. Claim # ___________________________ Insurer Mailing Address _____________________________________________________________________ City, State, ZIP _____________________________________________________________________________ Date compensation was denied _________________ Date claimant was notified of denial _________________ Basis for denial ____________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Printed name of submitter ____________________________________________ Phone # _________________ Signature ___________________________________________________________ Date __________________ Email _____________________________________________________ Fax # __________________________ LB-0283 (REV 11/15) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com