Tennessee Bureau of Workers' Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 FORM C-41 WAGE STATEMENT EMPLOYEE: ________________________________ SSN: STATE FILE #: Employer _________________________________ Ins Claim # ____________________ Date of Injury: ________________ Please list the wages earned by the employee named above during each of the 52 weeks prior to date of injury, if applicable. GROSS WAGES GROSS WAGES WEEK 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 WEEK ENDING WEEK 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 WEEK ENDING TOTAL PAID Date: Name of Preparer and Title _______________________________________________________ LB-0384 (REV 11/15) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com