Request For Prior Work Injury Info {LB-3271}

LB-3271 (7/18) RDA 10183 STATE OF TENNESSEE BUREAU OF WORKERS222 COMPENSATION 220 FRENCH LANDING DRIVE NASHVILLE, TENNESSEE 37243-1002 615-253-1842 or fax 615-532-8546 WC.Claims@tn.gov REQUEST FOR PRIOR WORK INJURY INFORMATION This form is used to satisfy the requirement of T.C.A 50-3-702(b), which allows employers to verify the truthfulness of a job applicant concerning a possible prior work injury. NOTE: There is a $10.00 fee for this service for each applicant named below. The Bureau will invoice the requester for the fee(s) after the records have been provided. Employer d/b/a Name Requester Name Requester Direct Phone # Title Street Address 1 Street 2 City State ZIP Please indicate the manner in which you want the invoice and search results returned to you. Fax or Email Signature of Requester Date Job App licant(s) Name (to be provided by the employer) Applicant(s) SSN (to be provided by the employer) # of Records Found (to be provided by the Bureau) American LegalNet, Inc. www.FormsWorkFlow.com