| Title |
Last Updated |
| Standard Form Medical Report For Industrial Injuries |
May 24, 2019 |
| Notice Of Corporate Officers Revocation Of Exemption |
May 24, 2019 |
| Notice Of Change Or Termination Of Compensation Benefits |
May 24, 2019 |
| Request For Administrative Review Of A WC Specialists Order |
November 7, 2018 |
| Notice Of Acceptance Of Workers Compensation Act |
September 26, 2018 |
| Petition For Benefit Determination |
June 15, 2018 |
| Agreement Between Employer - Employee Choice Of Physician Form |
April 13, 2015 |
| Petition for Benefit Determination |
February 27, 2015 |
| Notice Of Discontinuance Of Form I-18 - Election Of Non Coverage By Subcontractor |
September 2, 2014 |
| Case Management Closure Instructions |
October 31, 2013 |
| Application For Appointment To The Medical Impairment Rating (MIR) Registry |
October 31, 2013 |
| Permanent Total Disability Final Order |
April 3, 2013 |
| Medical Waiver And Consent |
April 3, 2013 |
| Medical Care Cost Containment Committee Review Request |
April 3, 2013 |
| Employees Choice Of Physician |
April 3, 2013 |
| Request For Settlement Approval |
July 11, 2012 |
| Tennessee Workers Compensation Insurance Notice To Be Posted At Employers Place Of Business (Spanish) |
June 25, 2012 |
| Tennessee Workers Compensation Insurance Notice To Be Posted At Employers Place Of Business |
June 25, 2012 |
| Request For Benefit Review Conference |
June 25, 2012 |
| Request For Assistance |
June 25, 2012 |
| Notice Of Corporate Officer Not To Accept Workers Compensation Act |
June 25, 2012 |
| Medical Impairment Rating (MIR) Impairment Rating Report 6th Edition |
June 25, 2012 |
| Certificate Of Readiness |
June 25, 2012 |
| Case Manager Registration |
June 25, 2012 |
| Application For A Medical Impairment Rating (MIR) |
June 25, 2012 |
| Workers Compensation Statistical Data Form |
December 4, 2010 |
| Case Management Notification |
December 4, 2010 |
| Notice Of Controversy |
December 4, 2010 |
| Request For Assistance (Or Mediation) |
December 3, 2010 |
| Provider Registration For Utilization Review |
December 3, 2010 |
| Medical Waiver And Consent |
December 3, 2010 |
| Final Medical Report |
December 3, 2010 |
| Beneifit Review Conference Certificate Of Readiness |
December 3, 2010 |
| Application - TN Drug Free Work Place Premium Credit Program |
December 3, 2010 |
| Notice Of Withdrawal Of Waiver |
September 25, 2008 |
| Notice Of Waiver By Employee For Benefits In Claims Growing Out Of Aggravation Or Repetition Of Heart Disease |
September 25, 2008 |
| Notice Of Waiver By Employee For Benefits In Claims Arising Out Of Occupational Diseases |
September 25, 2008 |
| Employees Choice Of Physician |
September 25, 2008 |
| Wage Statement |
September 25, 2008 |
| Notice Of Waiver By Employee For Benefits From Injuries Resulting From Epilepsy |
September 24, 2008 |
| Notice Of Termination Of Agreement Of General Contractor With Subcontractor |
September 24, 2008 |
| Notice Of Termination Of Agreement Of Common Carrier With Leased Operator And Or Leased Owner-Operator |
September 24, 2008 |
| Medical Impairment Rating (MIR) Medical Waiver And Consent |
September 24, 2008 |
| Agreement Of General Contractor To Provide Workers Compensation Coverage To Subcontractor |
September 24, 2008 |
| Agreement Of Common Carrier To Provide WC Coverage To Leased Operator And Or Leased Owner-Operator |
September 24, 2008 |
| Notice Of Withdrawal Of Exempt Employers Voluntary Election |
January 25, 2008 |
| Notice Of Corporate Officer To Employer Of Election Not To Accept Provisions Of Workers Compensation Act Of Tennessee |
January 25, 2008 |
| Notice Of Withdrawal Of Sole Proprietor Or Partner Election |
January 25, 2008 |
| Utilization Review Notification |
January 25, 2008 |
| Notice Of Withdrawal From Coverage Of The Tennessee Workers Compensation Law |
January 25, 2008 |
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