______________________ RFA NUMBER _______________________________ STATE FILE NUMBER C40R TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers’ Compensation http://www.state.tn.us/labor-wfd/wcomp.html Toll Free: 1-800-332-2667 CERTIFICATE OF READINESS FOR BENEFIT REVIEW CONFERENCE This Certificate is to be filed only if you have previously filed Form C40B Request for Benefit Review Conference Employee: _________________________________________ Email: Ph: SS #: _______________________ Date of Injury: _____________ Employer: EE Counsel: ____________________________Email : _________________Fax Address: City: Ph State: _______ Zip: Insurance: __________________________ Claims Handler: ___________________ Email: Address: City: State: _______ Zip: ER Counsel: ____________________________Email : _______________________Fax Address: City: Ph State: _______ Zip: Is the Second Injury Fund involved with this claim? _____ Yes _____ No SIF Attorney The undersigned party or party’s representative certifies each or the following to be true: □ □ □ □ A request for Benefit Review conference has been or is being filed in this matter. An employee has reached Maximum Medical Improvement and an impairment rating has been given Date of MMI: Rating: Body Part: All of the needed information regarding this claim has been exchanged with other parties and all parties agree that no additional discovery is needed. All parties have discussed dates for conducting mediation and the parties and/or their representatives have agreed on the dates listed below. Please Note: Dates are subject to availability. The parties request that the BRC be scheduled on one of the following dates within the next 60 days. (circle one) (circle one) (circle one) ___________ 9:00 a.m. ___________ 9:00 a.m. ___________ 9:00 a.m. 1st Choice 1:00 p.m. 2nd Choice 1:00 p.m. 3rd Choice 1:00 p.m. Comments: Identify requesting Party: Employee ____ Employer ____ Requesting Party’s Printed Name Identify which Party or Representative Requesting Party’s Signature Opposing Party’s Printed Name Identify which Party or Representative Opposing Party’s Signature Second Injury Fund Representative; if applicable (print) Second Injury Fund Signature; if applicable LB-0973 (rev. 07/2010) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com