<p> TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT C20 EMPLOYER’S FIRST REPORT OF WORK INJURY OR ILLNESS R</p><p>E JURISDICTION CLAIM # (STATE FILE #) CLAIM TYPE CODE I</p><p>R The use of this form is required under the provisions of R MED ONLY A the Tennessee Workers' Compensation Law and must C / CLAMS ADM CLAIM # (INSURER CLAIM #) INDEMNITY be completed and filed with your insurance carrier M</p><p>D BECAME LOST TIME immediately after notice of injury.</p><p>A </p><p>S OSHA LOG CASE # BECAME MED ONLY It is a crime to knowingly provide false, incomplete or M I</p><p>A misleading information to any party to a workers'</p><p>L NOTIFY ONLY </p><p>C compensation transaction for the purpose of TRANSFER committing fraud. Penalties include imprisonment, NAME OF INSURANCE CARRIER CARRIER FEIN fines and denial of insurance benefits. If you have questions, the state now has a benefit CLAIMS ADMIN FIRM NAME (if different from carrier) FEIN OF CLMS ADM review system where a Workers' Compensation Specialist can provide assistance. Call 1-800-332-2667 CLAIMS ADJUSTER NAME CLMS ADJ PHONE # (TDD).</p><p>CLAIM HANDLING OFFICE ADDRESS LINE 1 AND LINE 2 CITY STATE ZIP R</p><p>E EMPLOYER NAME EMPLOYER FEIN SIC CODE PHONE NUMBER Y O L P NATURE OF BUSINESS M EMPLOYER ADDRESS LINE 1 AND LINE 2</p><p>E</p><p>CITY STATE ZIP INSURED REPORT NUMBER EMPLOYER LOCATION #</p><p>Y EMPLOYMENT STATUS CODE C INSURED NAME (parent co. if different than employer) POLICY NUMBER EFF DATE I L</p><p>O FULL TIME/REGULAR P SELF INSURED? EXP DATE PART TIME YES NO</p><p>E PIECE WORKER</p><p>E EMPLOYEE LAST NAME PHONE INCL AREA CODE GENDER Y SEASONAL</p><p>O </p><p>L MALE P VOLUNTEER M FIRST MI DEPARTMENT REGULARLY FEMALE E WORKED APPRENTICE FULL TIME UNKNOWN APPRENTICE PART TIME ADRRESS LINE 1 & 2 OCCUPATION DESCRIPTION</p><p>CITY STATE ZIP MARITAL STATUS MARRIED NCCI CLASS CODE UNMARRIED, SINGLE, SEPARATED SSN DATE OF BIRTH DATE OF HIRE DIVORCED UNKNOWN</p><p>E NUMBER OF DAYS WORKED PER WEEK G WAGE PERIOD WEEKLY SALARY CONTINUED IN LIEU OF COMPENSATION YES NO A</p><p>W $ HOURLY BI WEEKLY - FULL WAGES PAID FOR DATE OF INJURY YES NO DAILY MONTHLY Y</p><p>R DATE OF INJURY TIME OF INJURY AM PM TIME EMPLOYEE BEGAN WORK ON INJURY DATE U J</p><p>N AM </p><p>I COULD NOT BE DETERMINED /</p><p>T PM N E DATE EMPLOYER NOTIFIED OF INJURY BODY PART AFFECTED CODE NATURE OF INJURY CODE CAUSE OF INJURY CODE D I C C A DATE CLAIM ADM NOTIFIED OF INJURY 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. DATE LAST DAY WORKED</p><p>DATE DISABILITY BEGAN</p><p>RETURN TO WORK DATE (IF APPLICABLE)</p><p>DATE OF DEATH (IF APPLICABLE) IF DEATH CLAIM, GIVE # DEPENDENTS FOR EACH RELATIONSHIP WIDOW FATHER ____ SISTER TOTAL # DEPENDENTS DID INJURY ILLNESS OCCUR ON EMPLOYER S ____ BROTHER / ’ WIDOWER ____ DAUGHTER PREMISES YES NO ____ SON ____ HANDICAPPED CHILD ? MOTHER ADDRESS WHERE INJURY OCCURRED (if other than employer’s premises) COUNTY OF INJURY CITY STATE ZIP</p><p>T HOSPITAL OR OFF SITE TREATMENT NAME N PHYSICIAN NAME E M T</p><p>A ADDRESS LINE 1 AND 2 E ADDRESS LINE 1 AND 2 R T</p><p>CITY STATE ZIP CITY STATE ZIP</p><p>INITIAL TREATMENT MINOR BY EMPLOYER HOSPITALIZED > 24 HRS FUTURE MAJOR MEDICAL/LOST TIME NO MEDICAL TREATMENT MINOR BY CLINIC/HOSPITAL EMERGENCY CARE ANTICIPATED R</p><p>E DATE PREPARED PREPARER’ NAME & TITLE PREPARER’S COMPANY NAME PHONE NUMBER H T O LB-0021 (REV 12-01)</p>