FORM C-22 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 NOTICE OF FIRST PAYMENT OF 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 ___________________ Date First Payment (mailed/delivered) ________________ Amount of Payment __________________ Compensation Payment From__________________ To _______________________________ Average Weekly Wage ______________________ Weekly Compensation Rate ___________ Check Appropriate Box Temporary Total Disability Benefits Temporary Partial Disability Benefits Permanent Partial Disability Benefits Permanent Total Disability Benefits Death Benefits This notice serves as certification of payment of workers' compensation benefits as above stated. _______________________________________________________________________________ Insurer/Self Insurer/Claim Handler _______________________________________________________________________________ Address _______________________________________________________________________________ Address _______________________________________________________________________________ Date LB-0024 (REV. 12/07) RDA10183 American LegalNet, Inc. www.FormsWorkflow.com