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

MED ONLYINDEMNITYBECAME LOST TIMEBECAME MED ONLYNOTIFY ONLYTRANSFER
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?

YESNO
EFF DATE

MonthDayYear
Date
EXP DATE

MonthDayYear
Date
EMPLOYEE
EMPLOYEE LAST NAME*
FIRST NAME*
MIDDLE INITAL*
ADDRESS*
CITY*
STATE*
ZIP*
PHONE INCL AREA CODE*
Format: (000) 000-0000.
DEPARTMENT REGULARLY WORKED*
GENDER*

MALEFEMALEUNKNOWN
EMPLOYMENT STATUS CODE*

FULL TIME / REGULARPART TIMEPIECE WORKERSEASONALVOLUNTEERAPPRENTICE FULL TIMEAPPRENTICE PART TIME
OCCUPATION DESCRIPTION*
MARITAL STATUS*

MARRIEDUNMARRIED, SINGLE,SEPARATEDDIVORCEDUNKNOWN
NCCI CLASS CODE
SSN*
DATE OF BIRTH*

MonthDayYear
Date
DATE OF HIRE

MonthDayYear
Date
WAGE
WAGE $*
PERIOD*

HOURLYDAILYWEEKLYBI-WEEKLYMONTHLY
NUMBER OF DAYS WORKED PER WEEK*
SALARY CONTINUED IN LIEU OF COMPENSATION

YESNO
FULL WAGES PAID FOR DATE OF INJURY

YESNO
ACCIDENT / INJURY
DATE OF INJURY*

MonthDayYear
Date
TIME OF INJURY*
TIME OF INJURY*

AMPMCOULD NOT BE DETERMINED
TIME EMPLOYEE BEGAN WORK ON INJURY DATE*
TIME EMPLOYEE BEGAN WORK ON INJURY DATE*

AMPM
DATE EMPLOYER NOTIFIED OF INJURY*

MonthDayYear
Date
BODY PART AFFECTED CODE*
NATURE OF INJURY CODE*
CAUSE OF INJURY CODE*
DATE CLAIM ADM NOTIFIED OF INJURY*

MonthDayYear
Date
DATE LAST DAY WORKED*

MonthDayYear
Date
DATE DISABILITY BEGAN

MonthDayYear
Date
RETURN TO WORK DATE (IF APPLICABLE)

MonthDayYear
Date
DATE OF DEATH (IF APPLICABLE)

MonthDayYear
Date
DID INJURY/ILLNESS OCCUR ON EMPLOYER’S PREMISES?*

YESNO
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

WIDOWWIDOWERMOTHERFATHERDAUGHTERSONSISTERBROTHERHANDICAPPED CHILD
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*

NO MEDICAL TREATMENTMINOR BY EMPLOYERMINOR BY CLINIC/HOSPITALHOSPITALIZED >24 HRSEMERGENCY CAREFUTURE MAJOR MEDICAL/LOST TIME ANTICIPATED
OTHER INFORMATION
DATE PREPARED*

MonthDayYear
Date
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