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Notice Of Lawsuit Form. This is a Tennessee form and can be use in Workers Compensation.
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Tags: Notice Of Lawsuit, C-28, Tennessee Workers Compensation,
FORM C-28
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Dr.
Nashville, Tennessee 37243-1002
NOTICE OF LAWSUIT
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 #: ______________________________
Soc Sec # ________________________________
Employer _________________________
Claimant _________________________________
Address __________________________
Address __________________________________
FEIN # __________________________
Insurer ___________________________________
Insurer Claim# ____________________
Insurer Address _________________________________________________________________
Date of Injury _____________________________
Date of Disability __________________
Petitioner ___________________________________ hereby notifies the Tennessee Workers'
Compensation Division of filing of lawsuit in the captioned claim.
Matters in dispute: _______________________________________________________________
______________________________________________________________________________
Date lawsuit filed: _______________________________________________________________
County and Court of filing: ________________________________________________________
Docket #: ______________________________________________________________________
Attorney Filing and Firm Name: ____________________________________________________
Name
________________________________________________
Address
________________________________________________
Address
Dated this ________ day of ____________________________, 20 ________.
A COPY OF LAWSUIT MUST ACCOMPANY THIS FORM
LB-0284 (REV. 12/07)
RDA 10183
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