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FORM C42 DIVISION OF WORKERS COMPENSATION TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOP ME NT 220 French Landing Dr. Nashville, Tennessee 372431002 AGREEMENT BETWEEN EMPLOYER/EMPLOYEE CHOICE
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How to fill out division of workers compensation:

01
Gather all relevant information: Before starting to fill out the division of workers compensation form, make sure you have all the necessary information, such as the employee's name, job title, date of injury, and any medical documentation or reports related to the injury.
02
Provide details about the injury: In the form, you will need to provide a detailed description of how the injury occurred. Include important information such as the date, time, and location of the incident, as well as any contributing factors or witnesses.
03
Specify the medical treatment received: Indicate the medical treatment the injured employee has received for their injury. This may include visits to doctors, specialists, or therapists, as well as any prescribed medications or ongoing treatments.
04
Document work restrictions or limitations: If the injury has resulted in any work restrictions or limitations for the employee, make sure to clearly outline these in the form. Include details about any temporary or permanent restrictions that may affect the employee's ability to perform their job duties.
05
Provide information about lost wages: If the injury has caused the employee to miss work and lose wages, you will need to provide information about their average weekly wage and the number of days or hours they were unable to work. This will help determine the compensation they may be entitled to.
06
Submit supporting documentation: Along with the completed form, attach any relevant supporting documentation, such as medical reports, invoices, or witness statements. These documents can help provide additional evidence to support the workers' compensation claim.

Who needs division of workers compensation?

01
Employees who have suffered a work-related injury or illness may need to file a division of workers compensation. This includes individuals who have been injured on the job, developed an occupational disease, or experienced a work-related aggravation of a pre-existing condition.
02
Employers are responsible for providing workers' compensation benefits to eligible employees. They may need to request division of workers compensation forms from their insurance provider or state workers' compensation agency in order to start the claims process.
03
Insurance companies and state workers' compensation agencies require division of workers compensation forms to determine the eligibility of the claim and to provide appropriate benefits to injured employees.
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Division of workers compensation is a form or report that must be filed by employers to report any work-related injuries or illnesses suffered by employees.
All employers who have employees covered under workers compensation insurance are required to file division of workers compensation.
Division of workers compensation can usually be filled out online on the state's workers compensation website or through a paper form provided by the insurance provider.
The purpose of division of workers compensation is to ensure that injured employees receive the benefits they are entitled to and to track work-related injuries for statistical and safety improvement purposes.
Information that must be reported on division of workers compensation includes details of the injury or illness, the employee's job description, and any medical treatment received.
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