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Fill and Sign the Tennessee Wage Statement for Workers Compensation Form

Fill and Sign the Tennessee Wage Statement for Workers Compensation Form

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Open the document and fill out all its fields.
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LB -0384 (REV 11/15) RDA 10183 Tennessee Bureau of Workers’ Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 FORM C- 41 WAGE STATEMENT EMPLOYEE: ________________________________ SSN: STATE FILE #: Employer _________________________________ Ins Claim # ____________________ Date of Injury: __ ______________ Please list the wages earned by the employee named above during each of the 52 weeks prior to date of injury, if applicable. WEEK WEEK ENDING GROSS WEEK WEEK ENDING GROSS WAGES WAGES 1 27 2 28 3 29 4 30 5 31 6 32 7 33 8 34 9 35 10 36 11 37 12 38 13 39 14 40 15 41 16 42 17 43 18 44 19 45 20 46 21 47 22 48 23 49 24 50 25 51 26 52 TOTAL PAID Date: Name of Preparer and Title _______________________________ ________________________

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