FORM C-27 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 NOTICE OF CONTROVERSY 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 #: _________________________ Claimant _________________________________ Employer ________________________________ Social Security # ___________________ FEIN # __________________________ Employer Address _______________________________________________________________ Insurer __________________________________ Insurer Claim# ____________________ Insurer Address _________________________________________________________________ Date of Injury _____________________________ Date of Disability __________________ ___________________________________ Insurer/Self Insurer ___________________________________ Address ___________________________________ Address Notice is hereby given to the Tennessee Workers' Compensation Division of controversy in the captioned workers' compensation claim. Date Compensation benefits stopped ________________________________________________ Matters in dispute _______________________________________________________________ ______________________________________________________________________________ Date claimant notified ____________________________________________________________ ____________________________________ Signature Dated this __________ day of _____________, 20 ________. LB-0280 (REV. 12/07) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com