Roane County Government - C-20 Workers Comp / Employer's First Report

TENNESSEE BUREAU OF WORKERS' COMPENSATION - EMPLOYER’S FIRST REPORT OF WORK INJURY OR ILLNESS
THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE TENNESSEE WORKERS' COMPENSATION LAW AND MUST BE COMPLETED AND FILED WITH YOUR INSURANCE CARRIER IMMEDIATELY AFTER NOTICE OF INJURY.

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.

IF YOU HAVE QUESTIONS, THE STATE NOW HAS A BENEFIT REVIEW SYSTEM WHERE A WORKERS' COMPENSATION SPECIALIST CAN PROVIDE ASSISTANCE. CALL 1-800-332-2667 (TDD).
CLAIMS ADM/CARRIER
JURISDICTION CLAIM # (STATE FILE #)
CLAIM TYPE CODE
CLAIMS ADM CLAIM # (INSURER CLAIM #)
OSHA LOG CASE #
NAME OF INSURANCE CARRIER
CARRIER FEIN
CLAIMS ADMIN FIRM NAME (IF DIFFERENT FROM CARRIER)
FEIN OF CLMS ADM
CLAIMS ADJUSTER NAME
CLMS ADJ PHONE #
Please enter a valid phone number.Format: (000) 000-0000.
CLAIM HANDLING OFFICE ADDRESS

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
EMPLOYER
EMPLOYER NAME
EMPLOYER FEIN
SIC CODE
PHONE NUMBER
Format: (000) 000-0000.
EMPLOYER ADDRESS
CITY
STATE
ZIP
NATURE OF BUSINESS
INSURED REPORT #
EMPLOYER LOCATION
POLICY
INSURED NAME (PARENT CO. IF DIFFERENT THAN EMPLOYER)
POLICY NUMBER
SELF INSURED?
EFF DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
EXP DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
EMPLOYEE
EMPLOYEE LAST NAME
FIRST NAME
MIDDLE INITAL
ADDRESS
CITY
STATE
ZIP
PHONE INCL AREA CODE
Format: (000) 000-0000.
DEPARTMENT REGULARLY WORKED
GENDER
EMPLOYMENT STATUS CODE
OCCUPATION DESCRIPTION
MARITAL STATUS
NCCI CLASS CODE
SSN
DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DATE OF HIRE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
WAGE
WAGE $
PERIOD
NUMBER OF DAYS WORKED PER WEEK
SALARY CONTINUED IN LIEU OF COMPENSATION
FULL WAGES PAID FOR DATE OF INJURY
ACCIDENT / INJURY
DATE OF INJURY

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
TIME OF INJURY
TIME OF INJURY
TIME EMPLOYEE BEGAN WORK ON INJURY DATE
TIME EMPLOYEE BEGAN WORK ON INJURY DATE
DATE EMPLOYER NOTIFIED OF INJURY

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
BODY PART AFFECTED CODE
NATURE OF INJURY CODE
CAUSE OF INJURY CODE
DATE CLAIM ADM NOTIFIED OF INJURY

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DATE LAST DAY WORKED

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DATE DISABILITY BEGAN

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
RETURN TO WORK DATE (IF APPLICABLE)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DATE OF DEATH (IF APPLICABLE)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DID INJURY/ILLNESS OCCUR ON EMPLOYER’S PREMISES?
HOW INJURY OR ILLNESS OCCURRED. DESCRIBE THE INCIDENT INCLUDING WHAT THE EMPLOYEE WAS DOING JUST BEFORE, THE PART OF THE BODY AFFECTED AND HOW, AND OBJECT OR SUBSTANCE THAT DIRECTLY HARMED THE EMPLOYEE.
IF DEATH CLAIM, GIVE # DEPENDENTS FOR EACH RELATIONSHIP
TOTAL# DEPENDENTS
ADDRESS WHERE INJURY OCCURRED (IF OTHER THAN EMPLOYER’S PREMISES)
CITY
STATE
ZIP
COUNTY OF INJURY
TREATMENT
PHYSICIAN NAME
PHYSICIAN ADDRESS
CITY
STATE
ZIP
HOSPITAL OR OFF SITE TREATMENT NAME
HOSPITAL OR OFF SITE TREATMENT ADDRESS
CITY
STATE
ZIP
INITIAL TREATMENT
OTHER INFORMATION
DATE PREPARED

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PREPARER’S NAME & TITLE
PREPARER’S COMPANY NAME
PHONE NUMBER
Format: (000) 000-0000.
Should be Empty:

TENNESSEE BUREAU OF WORKERS' COMPENSATION - EMPLOYER’S FIRST REPORT OF WORK INJURY OR ILLNESS

CLAIMS ADM/CARRIER

EMPLOYER

POLICY

EMPLOYEE

WAGE

ACCIDENT / INJURY

TREATMENT

OTHER INFORMATION