FORM C-23 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 NOTICE OF DENIAL OF CLAIM FOR COMPENSATION 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 _________________________________ Social Security # ___________________ Employer _________________________________ FEIN # ___________________________ Employer Address _______________________________________________________________ Insurer ___________________________________ Insurer Claim# ____________________ Insurer Address _________________________________________________________________ Date of Injury ______________________________ Date of Disability ___________________ 1. Date compensation was denied: ___________________________________________________ 2. Date claimant was notified of denial: ______________________________________________ 3. Date doctors were notified of denial: _______________________________________________ State basis for denial of compensation: _______________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _____________________________________ Insurer/Self Insurer ____________________________________________ Address ____________________________________________ Address _____________________________________ Phone/Fax/Email of Sender Date ________________________________ LB-0283 (REV. 12/07) RDA 10183 American LegalNet, Inc. www.FormsWorkflow.com