Tennessee Bureau of Workers222 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