COMPENSATION HEARING NOTICE OF APPEAL www.tn.gov/labor - wfd/wcomp.shtml wc.courtclerk@tn.gov 1 - 800 - 332 - 2667 Docket #: State File #/YR: Employee Employer Notice Notice is given that [List name(s) of all appealing party(ies) on separate sheet if necessary] appeals the order(s) Compensation Appeals Board. [List the date(s) the order(s) was filed in the court office] Judge Statement of the Issues Provide a short and plain statement of the issues on appeal or basis for relief on appeal: List of Parties Appellant (Requesting Party): At Hearing: Employer Employee Address: Phone: Email: Name: BPR#: Address: Phone: City, State & Zip code: Email: * Attach an additional sheet for each additional Appellant * RDA 118 LB-1 rev. /1 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Employee Name: SF#: DOI: Appellee(s) Appellee (Opposing Party):At Hearing: Employer Employee Email: BPR#: Phone: Address: Phone: Name: Address: City, State & Zip code: Email: *Attach an additional sheet for each additional Appellee * CERTIFICATE OF SERVICE , certify that I have forwarded a true and exact copy of this Compensation Hearing Notice of Appeal by First Class, United States Mail, postage prepaid, to all parties and/or their attorneys in this case in accordance with Rule 0800-02-22.01(2) of the Tennessee Rules of on this the day of , 20. [Signature of appellant or attorney for appellant] Board. If you wish to appeal a case to the Tennessee Supreme Court, please utilize the form provided by the Court which can be found on their website at the following address: http://www.tncourts.gov/sites/default/files/docs/noticeofappeal-civilorcriminal.pdf LB-1 rev. /1 American LegalNet, Inc. www.FormsWorkFlow.com