Get Form C-27 - Tn

Filling out Form C-27 - Tn is a crucial step in managing your workers' compensation claim in Tennessee. This guide provides clear and comprehensive instructions to help you complete the form accurately and efficiently online.

Follow the steps to complete Form C-27 - Tn online.

1. Press the ‘Get Form’ button to retrieve the form and open it in your editor.
2. Locate the 'State File #' section and enter the specific file number related to your claim.
3. In the 'Claimant' field, write your full name as the individual filing the claim.
4. Provide your Social Security number in the designated area.
5. Enter the name of your employer in the 'Employer' field.
6. Fill in the Employer Federal Employer Identification Number (FEIN) in the appropriate spot.
7. Complete the 'Employer Address' section with the full address of your employer.
8. Identify the insurer by entering their name in the 'Insurer' field.
9. Record the Insurer Claim number if applicable.
10. Provide the full address of the insurer in the 'Insurer Address' section.
11. Indicate the date of the injury in the 'Date of Injury' field.
12. Fill in the 'Date of Disability' field with the relevant date.
13. Specify whether the entity is an insurer or self-insurer.
14. In the 'Notice is hereby given' section, describe the controversy in the workers' compensation claim.
15. Enter the date when compensation benefits stopped in the designated space.
16. Provide details about the matters in dispute regarding the claim.
17. State the date the claimant was notified in the appropriate field.
18. Sign the form where indicated, including the date of signing.
19. Once all fields are complete, you can save your changes, download, print, or share the completed form.

Complete your Form C-27 - Tn online today to ensure your workers' compensation claim is processed efficiently.