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303 N. Church St. RUTHERFORD COUNTY GOVERNMENT Phone: (615) 898-7715
Murfreesboro, TN 37130 "ON-THE-JOB INJURY" CLAIM REPORT Fax: (615) 867-4602
     

I hereby understand that all OJI Claims are investigated by the Rutherford County (RC) Insurance Department. Completion of an OJI Claim Report or attempting to file a claim does not guarantee acceptance of the individual claim. Therefore, after a full investigation of a claim, the claim may be non-compensable although the injured employee may have already seen an OJI physician with OJI office approval. If that occurs, bills prior to the investigation will be paid in full by the Insurance Department with the understanding that the injured employee will be responsible for any further treatment or medication. I also understand the Safety Coordinator or their representative has the right to attend all visits with me and my physician.    
     
* Indicates required fields/information    


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(Office Use Only)      
Claim #:    
Date of Injury:  *      
Time of Injury:       
Date of Report:       
Employee Name:  *    
Gender:  *    
Date of Birth:       
Date of Hire:       
Social Security No:       
Address:    
City:    
State:    
Zipcode:       
Home Phone:       
Work Phone:       
Cell Phone:       
Work Email:  * If you don't have a county email address, please enter your supervisor's email address instead.      
Department Employee Works For: *    
Work Location:    
Injury Location:    
Time employee began work on the date of injury:       
       
       

Affected Area (Check All That Apply):
         
           
           
         
               
             
                   
                       


Injury Type (please check):    
     
     
                 

* Describe - please enter details of events causing injury. (Please be sure to enter what employee was doing just before the injury occurred.)
   

* Is Medical Attention Needed?  
     
If YES, please select from one of the providers listed below. Unauthorized physicians or failure to seek medical treatment within 7 days of the injury will result in your claim being denied.
1203 A Memorial Blvd 1525 South Church St. 1332 Hazelwood Drive 1227 Heil Quaker Blvd.
Murfreesboro, TN 37129 Murfreesboro, TN 37130 Smyrna, TN 37167 LaVergne, TN 37086
Phone: (615) 895-4855 Phone: (615) 217-7236 Phone: (615) 355-1338 Phone: (615) 641-3080

Please Note: Before seeking medical treatment, you MUST make immediate contact with the RC Insurance Department for approval.
(615-898-7715)
       
Filing Signature:  * Date:   
  Name and last 4 digits of SSN    


As is allowed by T.C.A. 50-6-106, Rutherford County (RC) has opted to withdraw from the Tennessee Worker's Compensation Act, and
instead has chosen to implement an On-The-Job Injury Program administered by the Rutherford County Insurance Department.
 
 * Please Complete the Missing Information