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 
                       CLAIMS ADM CLAIM #(INSURER CLAIM #)                    INDEMNITY                   TENNESSEE     WORKERS'COMPENSATION     LAW AND MUST  BE 
                                                                               BECAME LOST TIME           COMPLETED     AND   FILED   WITH  YOUR    INSURANCE   CARRIER
                                                                               BECAME MED ONLY            IMMEDIATELY AFTER NOTICE OF INJURY.
                       OSHA LOG CASE #                                         NOTIFY ONLY                IT IS A CRIME TO KNOWINGLY PROVIDE FALSE  INCOMPLETE, OR 
         CARRIER/                                                              TRANSFER                   MISLEADING  INFORMATION TO ANY PARTY TO A WORKERS'
                       NAME OF INSURANCE CARRIER                            CARRIER FEIN                  COMPENSATION  TRANSACTION  FOR THE PURPOSE OF COMMITTING 
                                                                                                          FRAUD.PENALTIES INCLUDE IMPRISONMENT ,FINES AND DENIAL OF 
                                                                                                          INSURANCE BENEFITS
                       CLAIMS ADMIN FIRM NAME (IF DIFFERENT FROM            FEIN OF CLMS ADM                                 .
                       CARRIER)                                                                           IF YOU HAVE QUESTIONS  THE,STATE NOW HAS  A  BENEFIT  REVIEW 
         CLAIMS ADM    CLAIMS ADJUSTER NAME                                 CLMS ADJ PHONE #              SYSTEM WHERE A      WORKERS'COMPENSATION      SPECIALIST CAN 
                                                                                                          PROVIDE ASSISTANCE.CALL 1-800-332-2667 (TDD).
                       CLAIM HANDLING OFFICE  ADDRESS LINE  1AND LINE 2                                                 CITY               STATE             ZIP

                       EMPLOYER NAME                                        EMPLOYER FEIN                       SIC CODE                     PHONE  NUMBER

                       EMPLOYER ADDRESS LINE  1AND LINE 2                                                                        NATURE OF BUSINESS

         E MPLOYER     CITY                                          STATE          ZIP                           INSURED REPORT #             EMPLOYER LOCATION

                       INSURED NAME (PARENT CO .IF DIFFERENT THAN           POLICY NUMBER                 EFF DATE                     EMPLOYMENT STATUS CODE
                       EMPLOYER)                                                                                                    FULL TIME/REGULAR
         POLICY                                                                   SELF INSURED?           EXP DATE                  PART TIME
                                                                                       YES     NO                                   PIECE WORKER
                       EMPLOYEE  LAST NAME                                  PHONE INCL AREA CODE          GENDER                    SEASONAL
                                                                                                              MALE                  VOLUNTEER
                       FIRST                                         MI     DEPARTMENT REGULARLY              FEMALE                APPRENTICE FULL TIME
                                                                            WORKED                            UNKNOWN               APPRENTICE PART TIME
                       ADRRESS LINE 1& 2                                                                  OCCUPATION DESCRIPTION

         EMPLOYEE      CITY                                          STATE          ZIP                   MARITAL STATUS               MARRIED      NCCI CLASS CODE 
                                                                                                              UNMARRIED ,SINGLE,       SEPARATED
                       SSN                                 DATE OF BIRTH        DATE OF HIRE                  DIVORCED                 UNKNOWN

                       WAGE         PERIOD            WEEKLY            NUMBER OF DAYS WORKED PER         SALARY CONTINUED IN LIEU OF COMPENSATION      YES      NO
                       $               HOURLY         BI-WEEKLY                   WEEK
         WAGE                          DAILY          MONTHLY                                             FULL WAGES PAID FOR DATE OF INJURY    YES     NO

                       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 
                       DATE LAST DAY WORKED                          HARMED THE EMPLOYEE.
         INJURY/       DATE DISABILITY BEGAN

                       RETURN TO WORK DATE (IF APPLICABLE )
         ACCIDENT
                       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             WIDOWER             ____DAUGHTER          ____BROTHER
                       PREMISES?   YES     NO                             MOTHER              ____ SON              ____ HANDICAPPED CHILD
                                            ADDRESS WHERE INJURY OCCURRED (IF OTHER THAN EMPLOYER’S PREMISES      )                              C  OUNTY OF INJURY
                                                                                      CITY                    STATE              ZIP
                       PHYSICIAN NAME                                                                           HOSPITAL OR OFF SITE TREATMENT NAME

                       ADDRESS LINE  1AND 2                                                                             ADDRESS LINE  1AND 2

                       CITY                               STATE       ZIP               CITY                                           STATE       ZIP
         TREATMENT
                       INITIAL TREATMENT                      MINOR BY EMPLOYER               HOSPITALIZED>24 HRS               FUTURE MAJOR MEDICAL/LOST TIME 
                          NO MEDICAL TREATMENT              MINOR BY CLINIC/HOSPITAL          EMERGENCY CARE                     ANTICIPATED
                       DATE PREPARED                 PREPARER’S NAME  &TITLE            PREPARER’S COMPANY NAME              PHONE  NUMBER
                  OTHER
LB-0021 (REV. 05/22)                                                                                                                                            RDA10183