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Monthly Report Of Non Compensable Injuries Or Diseases Form. This is a Tennessee form and can be use in Workers Compensation.
Tags: Monthly Report Of Non Compensable Injuries Or Diseases, C-21, Tennessee Workers Compensation,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
C-21
Index No.
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
:
Calendar No.
Division of Workers' Compensation
:
Nashville, Plaintiff(s)
Tennessee 37243-0661
JUDICIAL SUBPOENA
-against-
:
MONTHLY REPORT OF NON-COMPENSABLE INJURIES OR DISEASES
INSTRUCTIONS
:
It is a crime to knowingly provide false, incomplete or misleading information to any party to aworkers'
:
compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial
Defendant(s)
of insurance benefits.
:
......................................................
This report should include all claims closed in the previous month that resulted in lost time of seven days or less and/or
incurred medical expenses. The report should be filed with this division by the fifteenth day of the month, covering the
previous month. This report must contain the total medical expenses paid when closing out the claim.
THE PEOPLE OF THE STATE OF NEW YORK
Fatality claims, claims involving more than eight days lost time, or claims resulting in permanent disability must be
reported on Form C-20 First Report of Injury.
TO
INSURANCE CARRIER NAME ____________________________________________________
INSURANCE CARRIER ADDRESS _________________________________________________
REPORT FOR THE MONTH OF ______________________ IN THE YEAR ________________
GREETINGS:
CLAIMS OFFICE FILING THIS REPORT ______________________________________________
WE COMMAND YOU,EMPLOYER NAME &and excusesNUMBER NATURE OF and each of MEDICAL before
that all business FEDERAL ID being laid aside, you
you attend
DATE OF
DAYS
,
the Honorable
at the
Court
ACCIDENT
INJURY
LOST
EXPENSE
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
EMPLOYEE NAME
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
1.
2.
3.
4.
5.
NUMBER OF CASES WITHOUT LOSS TIME FROM WORK
____________
MEDICAL EXPENSE OF CASES WITHOUT LOSS TIME FROM WORK Address___________
$
Office and P.O.
NUMBER OF CASES WITH ONE TO SEVEN DAYS LOST FROM WORK
____________
TOTAL NUMBER OF LOST WORK DAYS (CUMULATIVE OF #3)
____________
MEDICAL EXPENSE WITH ONE TO SEVEN DAYS LOST FROM WORK
$ ___________
Telephone No.:
Facsimile No.:
TOTAL NUMBER OF CASES FROM LINES 1 Address:
____________
E-Mail AND 3
LB-0027 (rev. 8/99)
TOTAL MEDICAL EXPENSE FROM LINES 2 AND 5
$ ___________
Mobile Tel. No.:
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