Tennessee Required Postings and Forms
Download Tennessee Claims Kit
Please print and post the following notices, both in English and Spanish, in a conspicuous location frequented by employees such as the break room, lunch room or time clock. If you have multiple business locations, be sure to post the notices at each location.
- Workers’ Compensation Insurance Notice (English and Spanish)
- Anti-Fraud Notice (English and Spanish)
Please print and review the following forms with your current staff and new employees (at the time of hire):
- Form C-20 First Report of Injury (FROI). As soon as you have been notified of a work related injury, please fill out this form and submit it to EMPLOYERS®. This helps us to quickly provide a determination of compensability and issuance of benefits—helping keep the cost and time of a claim contained.
- Form C-41 Wage Statement. This form enables EMPLOYERS to calculate the correct compensation due to an injured employee. Please complete the form and submit to EMPLOYERS within 5 days after your knowledge of any accident that has caused your employee to be disabled for more than 7 calendar days.
- Form C-42/LB-0382 Agreement Between Employer/Employee Choice of Physician (English and Spanish). Upon the report of a work-related injury or occupational disease, an employer should provide the employee an Agreement Between Employer/Employee Choice Of Physician form. The form must indicate the name of the physician chosen by the injured employee, be signed and dated by the employee with a copy given to the employee, and the original kept on file with the employer and a copy forwarded to the carrier with the first report of work injury. The employer shall designate a group of three (3) or more independent reputable physicians or surgeons, chiropractors or specialty practice groups if available in the injured employee’s community, from which the injured employee shall select one (1) to be the treating physician. This form, signed by you (the employer) and employee, is your proof that your injured employee was offered a choice of physicians.
- First Fill Form. This form provides your employees with basic information about our Pharmacy Benefit Program, including such things as the phone number to call to locate a First Fill participating pharmacy. When your employee becomes injured, please print and complete this form and provide it to your injured employee. Your employee will need to provide this completed form along with the prescription for his/her work-related injury or occupational disease to the pharmacist. Using this form will help enable quick authorization for your employee’s initial medication and ensure that the initial prescription is provided at no cost to the injured employee.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 14791, Lexington, KY 40512-4791. You should also keep a copy on file for your records.
More Tennessee Workers’ Comp Resources
- Off-Site Transitional Duty Program – Helping Your Injured Employees Get Back to Work. A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.