Cover Sheet and Welcome Letter
Table of Contents
Instructions for Posters
LB-0922 – Tennessee Workers’ Compensation Insurance Posting Notice (Versión en Español)
Fraud Prevention Poster (Versión en Español)
Instructions for Injury Reports
LB-0021 – C-20 – Employer’s First Report of Work Injury or Illness
LB-0384 – C-41 – Wage Statement
Incident Investigation Report Form (Versión en Español)
Supervisor’s Report of Employee Incident (Versión en Español)
Witness Statement of Employee Incident (Versión en Español)
Instructions for Injured Worker Handouts
LB-0382 – C-42 – Employee’s Choice of Physician – Medical Panel (Versión en Español)
C-31B – Medical Waiver and Consent (Versión en Español)
Consent & Authorization for Release of Information (Versión en Español)
Request for Medical History (Versión en Español)
Injured Workers First Fill Prescription Form (Versión en Español)
Direct Deposit Authorization Form (Versión en Español)
LB-0030 – Combined I-10, I-11, I-12 – Notice of Waiver of Workers’ Compensation Benefits for Specific Medical Conditions (Versión en Español)
LB-0290 – Form I-13 – Notice of Withdrawal of a Previously Signed Waiver
Instructions for Informational Documents
Omaha National Contact Information
Reduce Your Workers Compensation Costs
Provider Panel Information for Employers
LB-3265 – Notice of Employer Rights and Responsibilities in a Workers’ Compensation Claim
Instructions for General Forms
Request for Subrogation Waiver
Form ERM-14 – Confidential Request for Ownership Information
Company Contacts Verification
Instructions for State-Specific Forms & Documents
LB-3271 – Request for Prior Work Injury Information
LB-0090 – I-6 – Notice of Corporate Officer to Employer of Election Not to Accept Provisions of Workers’ Compensation Act of Tennessee
LB-0288 – I-7 – Notice of Corporate Officer’s Revocation of Exemption
LB-0228 – I-4 – Notice of Election (Sole Proprietor, Member of LLC, or Partner) (Versión en Español)
LB-0287 – I-5 – Notice of Withdrawal (Sole Proprietor, Member of LLC, or Partner) (Versión en Español)
LB-0301 – Combined I-15 & I-17 – General Contractor Acceptance – Termination of Coverage Agreement
