Your weekly benefit rate (comp. rate) is a percentage of your average, weekly gross pay over the course of a 52-week period. In order to determine your comp. rate, employers will submit a Form C-41 to the Tennessee Department of Labor and Workforce Development, Division of Workers’ Compensation.
On this form, your employer lists your weekly gross wages for the past 52 weeks. Then, an average weekly wage is established from the weeks listed. Finally, you take 66 and 2/3 percent of the average weekly wage and you have found the comp. rate. There are also maximum and minimum rates that apply when a comp. rate is extremely high or extremely low. If you have questions about your weekly benefit rate, or any other portion of your workers’ compensation claim, please contact Attorney Cody Allison & Associates / The Work Comp. Team at (615) 234-6000.
Below is a copy of the C-41 Wage Statement from the Tennessee Department of Labor and Workforce Development.
FORM C-41
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Dr.
Nashville, Tennessee 37243-1002
WAGE STATEMENT
It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits.
State File #
Employee: SSN:
Insurer Claim #:
Date of Injury
In order to determine the correct rate of compensation to be paid to the above injured party, please fill in the schedule below and return it promptly. This information is required by law and no agreement for payment of compensation can be made until it has been received. Please complete 52 weeks prior to date of accident.
Please describe allowances of any character made in lieu of wages that must be deemed a part of employee's earnings:
Nashville, Tennessee workers’ compensation / Middle Tennessee workers’ compensation / Davidson County workers’ compensation
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