The Tennessee First Report form is a critical document required under the Tennessee Workers' Compensation Law. This form must be completed and submitted to your insurance carrier whenever an employee experiences a work-related injury or illness. Ensuring accurate and timely filing of this report is essential to facilitate the claims process and protect both the employer and employee rights.
To fill out the form, click the button below.
The Tennessee First Report form is a crucial document designed to streamline the reporting process for work-related injuries or illnesses. Employers must complete this form when an employee experiences an injury or illness that requires medical attention or results in lost time from work. The form captures essential information, including the nature of the injury, the circumstances surrounding the incident, and details about the employee and employer. It also requires the employer to indicate the type of claim being filed, whether it is a medical-only or indemnity claim. Accurate and timely submission of this form is not just a best practice; it is mandated by Tennessee’s Workers' Compensation Law. Failing to provide complete and truthful information can lead to serious consequences, including penalties for fraud. Additionally, the form includes sections for reporting the employee's work status, injury details, and treatment received, ensuring that all relevant information is documented. Employers should be aware that assistance is available through the state’s Benefit Review System, should they have questions about the process. By understanding the importance of the Tennessee First Report form, employers can better navigate the workers' compensation landscape and support their employees during challenging times.
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
EMPLOYER’S FIRST REPORT OF WORK INJURY OR ILLNESS
JURISDICTION CLAIM # (STATE FILE #)
CLAIM TYPE CODE
THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE
MED ONLY
TENNESSEE
WORKERS'
COMPENSATION
LAW
AND
MUST
BE
INDEMNITY
CLAIMS ADM CLAIM # (INSURER CLAIM #)
COMPLETED
FILED WITH
YOUR
INSURANCE
CARRIER
BECAME LOST TIME
IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR
TRANSFER
BECAME MED ONLY
IMMEDIATELY AFTER NOTICE OF INJURY.
OSHA LOG CASE #
NOTIFY ONLY
/
MISLEADING INFORMATION TO ANY PARTY TO A WORKERS'
ADM
NAME OF INSURANCE CARRIER
CARRIER FEIN
COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING
FRAUD.
PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF
CLAIMS
INSURANCE BENEFITS.
CLAIMS ADMIN FIRM NAME (IF DIFFERENT FROM
FEIN OF CLMS ADM
IF YOU HAVE QUESTIONS, THE STATE NOW HAS A BENEFIT REVIEW
CARRIER)
SYSTEM
WHERE A
WORKERS' COMPENSATION
SPECIALIST
CAN
CLAIMS ADJUSTER NAME
CLMS ADJ PHONE #
PROVIDE ASSISTANCE. CALL 1-800-332-2667 (TDD).
CITY
CLAIM HANDLING OFFICE ADDRESS LINE 1 AND LINE 2
STATE
ZIP
EMPLOYER NAME
EMPLOYER FEIN
SIC CODE
PHONE NUMBER
MPLOYERE
INSURED REPORT #
EMPLOYER LOCATION
EMPLOYER ADDRESS LINE 1 AND LINE 2
NATURE OF BUSINESS
POLICY
INSURED NAME (PARENT CO. IF DIFFERENT THAN
POLICY NUMBER
EFF DATE
EMPLOYMENT STATUS CODE
EMPLOYER)
FULL TIME/REGULAR
SELF INSURED?
EXP DATE
PART TIME
YES
NO
GENDER
PIECE WORKER
EMPLOYEE LAST NAME
PHONE INCL AREA CODE
SEASONAL
MALE
VOLUNTEER
FIRST
MI
DEPARTMENT REGULARLY
FEMALE
APPRENTICE FULL TIME
EMPLOYEE
WORKED
UNKNOWN
APPRENTICE PART TIME
ADRRESS LINE 1 & 2
OCCUPATION DESCRIPTION
MARITAL STATUS
MARRIED
NCCI CLASS CODE
UNMARRIED, SINGLE,
SEPARATED
SSN
DATE OF BIRTH
DATE OF HIRE
DIVORCED
WAGE
PERIOD
WEEKLY
NUMBER OF DAYS WORKED PER
SALARY CONTINUED IN LIEU OF COMPENSATION
$
HOURLY
BI-WEEKLY
WEEK
FULL WAGES PAID FOR DATE OF INJURY
YES NO
DAILY
MONTHLY
DATE OF INJURY
TIME OF INJURY
AM PM
TIME EMPLOYEE BEGAN WORK ON INJURY DATE
COULD NOT BE DETERMINED
AM
PM
DATE EMPLOYER NOTIFIED OF INJURY
BODY PART AFFECTED CODE
NATURE OF INJURY CODE
CAUSE OF INJURY CODE
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
INJURY
DATE LAST DAY WORKED
HARMED THE EMPLOYEE.
DATE DISABILITY BEGAN
ACCIDENT/
RETURN TO WORK DATE (IF APPLICABLE)
IF DEATH CLAIM, GIVE #
DATE OF DEATH (IF APPLICABLE)
DEPENDENTS FOR EACH RELATIONSHIP
WIDOW
FATHER
____ SISTER
TOTAL # DEPENDENTS
WIDOWER
____ DAUGHTER
____ BROTHER
DID INJURY/ILLNESS OCCUR ON EMPLOYER’S
PREMISES?
MOTHER
____ SON
____ HANDICAPPED CHILD
ADDRESS WHERE INJURY
OCCURRED (IF OTHER THAN EMPLOYER’S PREMISES)
COUNTY OF INJURY
PHYSICIAN NAME
HOSPITAL OR OFF SITE TREATMENT NAME
TREATMENT
ADDRESS LINE 1 AND 2
INITIAL TREATMENT
MINOR BY EMPLOYER
HOSPITALIZED > 24 HRS
FUTURE MAJOR MEDICAL/LOST TIME
NO MEDICAL TREATMENT
MINOR BY CLINIC/HOSPITAL
EMERGENCY CARE
ANTICIPATED
OTHER
DATE PREPARED
PREPARER’S NAME & TITLE
PREPARER’S COMPANY NAME
LB-0021 (REV. 12/07)
RDA 10183
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