CERTIFICATE OF READINESS SF # TENNESSEE DEPT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers’ Compensation http://www.tn.gov/labor-wfd/wcomp.html Toll Free Help Line: 1-800-332-2667 STAMP- DATE RECEIVED RFA # This Certificate is to be filed ONLY if the Request for Benefit Review Conference –Form C40B was previously filed. The BRC will not be scheduled if information marked by asterisks on this form is missing. * * Date of Injury: * The Employee has reached Maximum Medical Improvement and a permanent impairment rating has been given. Employee’s Social Security Number: A Request for Benefit Review Conference in this matter was previously filed with the Division on MMI Date: Impairment Rating: Body Part: * All information regarding this claim has been exchanged between the parties or their representatives and all agree that no additional discovery is necessary. This includes any IME or MIRR ratings. * * The weekly compensation rate has been established. Yes No If applicable, the Second Injury Fund Attorney is and has been notified.  The Parties have discussed possible dates for conducting the mediation and all parties or their representatives have agreed upon the three dates and times listed below. (Circle Desired Time Slot) * * 9:00am / 1:00 pm * 9:00am / 1:00 pm 9:00am / 1:00 pm *CONTACT INFORMATION Employee EE’s Atty Address Address City State Ph# Zip City Fax# Ph# E-Mail Fax# ER’s Atty Address Zip E-Mail Employer State Address City State Ph# Zip City Fax# Ph# E-Mail State Zip Fax# E-Mail Ins. Carrier/Self-Insured Employer: Address City State Zip Adjuster Name: Ph# Fax# E-Mail By signing below, the Requesting party or party’s representative certifies all the above information to be true: * * Employee or Employee’s Representative (Print Name) * Employer or Employer’s Representative (Print Name) * Employee or Employee’s Representative (Signature) LB-0973 (Revised 03/2012) Employer or Employer’s Representative (Signature) Page 1 of 2 RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com TENNESSEE DEPT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers’ Compensation http://www.tn.gov/labor-wfd/wcomp.html Toll Free Help Line: 1-800-332-2667 Please return the completed form to the office listed below that is closest to the home address of the Employee named on the Certificate of Readiness-C40R form. If you need help in completing this form, please call the office nearest you or our toll-free help line listed above. CHATTANOOGA KINGSPORT TDLWD/WC DIVISION-BENEFIT REVIEW State Office Bldg, 600W 540 McCallie Avenue Chattanooga, TN 37402-2066 Phone: 423-634-6422 Fax: 423-634-3115 TDLWD/WC DIVISION-BENEFIT REVIEW 1908 Bowater Drive Kingsport, TN 37660-4136 Phone: 423-224-2057 Fax: 423-224-2056 KNOXVILLE COOKEVILLE TDLWD/WC DIVISION-BENEFIT REVIEW 1610 University Avenue, 2nd Floor Knoxville, TN 37921-6741 Phone: 865-594-5177 Fax: 865-594-5172 TDLWD/WC DIVISION-BENEFIT REVIEW 410 Spring Street, Suite G Cookeville, TN 38501-3791 Phone: 931-520-4290 Fax: 931-520-4316 MURFREESBORO NASHVILLE TDLWD/WC DIVISION-BENEFIT REVIEW 845 Esther Lane Murfreesboro, TN 37129-5537 Phone: 615-848-6743 Fax: 615-217-9378 TDLWD/WC DIVISION-BENEFIT REVIEW 2222 Rosa L. Parks Boulevard Nashville, TN 37228-1306 Phone: 615-741-1383 Fax: 615-253-1223 JACKSON MEMPHIS TDLWD/WC DIVISION-BENEFIT REVIEW 225 Dr. Martin L. King Jr. Drive 1st Floor, Suite 120, Box 26 Jackson, TN 38301-6985 Phone: 731-423-5646 Fax: 731-265-7022 TDLWD/WC DIVISION-BENEFIT REVIEW 170 North Main Street, 11th Floor Memphis, TN 38103-1820 Phone: 901-543-6077 Fax: 901-543-6039 LB-0973 Revised 03/2012) Page 2 of 2 RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com