Workers' Compensation Toolkit

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This kit is provided to new workers' compensation policyholders and their agents, as well as to all current policyholders when their policies renew. It contains important claims department contact information, instructions, and forms.


Tennessee Contact Information:

Nationwide Insurance - East Office
One Nationwide Gateway, Dept. 5570
Des Moines, IA 50391-5570
(800) 889-9872
Fax: (800) 363-8904

Harleysville Insurance
PO Box 244
Harleysville, PA 19438-0244
(888) 595-9876
Fax: (800) 441-4118

Agribusiness Mailing Address for Claims Related Mail
1100 Locust St., Dept 3010
Des Moines, IA, 50391-3010
Phone: (800) 228-6700
Fax: (800) 842-1482

 

NOTE: If you experience difficulty opening/accessing the PDF's using the links below:

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Tennessee Compliance Information

Posting Requirements

Reporting Of Claim By Employer

Penalties for Late Reporting

Physician Selection


Posters and Publications

POSTER - Tennessee Workers' Compensation Insurance Posting Notice Required


POSTER - Tennessee Workers' Compensation Insurance Posting Notice (Spanish) Required

POSTER - Drug Free Workplace Required

BROCHURE - A Guide to Workers' Compensation - date of accident prior to 7/1/2014

BROCHURE - A Guide to Workers' Compensation - date of accident on or after 7/1/2014


Forms

First Report of Work Injury


Wage Statement

Agreement Between Employer / Employee Choice of Physician

Agreement Between Employer / Employee Choice of Physician (Spanish)

Governemental Entities Agreement Between Employer / Employee Choice of Physician Form






Please Note: The information on this site is maintained by a third-party, Nationwide does NOT warrant or represent that the information will be error-free. Your use of the site is on an as-is basis, at your sole discretion and risk. The site is for informational purposes, and nothing included in the site shall replace the need for qualified legal counsel. We recommend that you consult with legal counsel, agents, or risk managers regarding workers' compensation obligations.

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