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FORM C-41 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers Compensation 220 French Landing Dr. Nashville Tennessee 37243-1002 WAGE STATEMENT 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. Employee SSN Insurer Claim State File Date of Injury In order to determine the correct rate of compensation to be paid to the above injured party please fill in the schedule below and return it promptly. This information is required by law and no agreement for payment of compensation can be made until it has been received* Please complete 52 weeks prior to date of accident. Please describe allowances of any character made in lieu of wages that must be deemed a part of employee s earnings If the average weekly wage is not based on fifty-two weeks of earnings proceeding the date of injury p....

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
C41 Form
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2015 TN Form C-41 LB-0384
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