LB-3263 (3/18) RDA 10183 STATE OF TENNESSEE BUREAU OF WORKERS222 COMPENSATION 220 FRENCH LANDING DRIVE NASHVILLE, TENNESSEE 37243-1002 (615)741-2395 or 1-800-332-2667 WC.EDI@TN.GOV NOTIFICATION OF PRIMARY LIAISON AND ADJUSTERS PROCESSING OR SUPERVISING TENNESSEE WORKERS222 COMPENSATION CLAIMS This form is used to satisfy the requirement for Adjusting Entities to designate a primary liaison and provide the names and contact information of each adjuster covered by the Bureau222s Claims Handling Standards (Rules 0800-2-14). In lieu of using this form, this information can be provided to the Bureau in another format if the same information is included. Information concerning adjusters must be provided to the Bureau in January and July of each year. Information concerning the primary liaison must be provided to the Bureau within 15 calendar days of any changes. Adjusting Entity Name d/b/a Primary Liaison Name Title Liaison Direct Phone # Email Liaison Street 1 Street 2 City State ZIP Adjuster Name Adjuster Direct Phone # Email Street 1 Street 2 City State ZIP Adjuster Name Adjuster Direct Phone # Email Street 1 Street 2 City State ZIP Adjuster Name Adjuster Direct Phone # Email Street 1 Street 2 City State ZIP Page of American LegalNet, Inc. www.FormsWorkFlow.com