Notice Of Change Or Termination Of Compensation Benefits {C-26}

LB-0285 (rev. 4/18) RDA 10183 Tennessee Bureau of Workers222 Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM C-26 NOTICE OF CHANGE OR TERMINATION OF COMPENSATION BENEFITS This form is used by adjusters to notify workers222 compensation claimants of a change or termination in the monetary amount of compensation benefits they will receive. This information must be provided to the Bureau, via EDI, within () business day of the change or termination and to the claimant, using this form, simultaneously with the notice to the Bureau. State File #: Insurer Claim # Claimant Name Employer Name Date of Injury Date of Disability CHANGE OF BENEFITS Compensation benefit rate changed from $ to $ Reason for change: Date of change: Date claimant notified: TERMINATION OF BENEFITS Date benefits terminated Date claimant notified: Reason for termination: INSURER/SELF-INSURER/TPA Adjuster Name (printed) Phone # Adjuster Email Address Date American LegalNet, Inc. www.FormsWorkFlow.com