REQUEST FOR ASSISTANCE 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 THIS FORM COVERS: RFA # Temporary Disability Benefits 25% Penalty (For Late or Non-Payment of Benefits) Medical Benefits Discovery Issues Open Medical Coverage PLEASE NOTE: ALL FIELDS MARKED WITH AN ASTERISK *ARE MANDATORY Failure to complete the required information on this form shall result in the form being returned to the requesting party for completion. * Please give a brief explanation of disputed issues: *SOCIAL SECURITY NUMBER: *DATE of INJURY: *DATE of BIRTH: A) *EMPLOYEE’S NAME: *Mailing Address: *City: *State: *County of Residence: *Telephone: Email: *If the Employee is represented by an attorney, all fields in this section are also mandatory. EE’s ATTORNEY: *Zip: BPR#: Mailing Address: City: Telephone: *State: Fax: *Zip: Email: *EMPLOYER NAME: *Contact: B) * Mailing Address: * City: *State: *Telephone: *Fax: *Email: *If the Employer is represented by an attorney, all fields in this section are also mandatory. ER’s ATTORNEY: *Zip: BPR#: Mailing Address: City: Telephone: LB-0381 (Revised 05/2012) *State: Fax: *Zip: Email: Page 1 of 3 RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com C) *INSURANCE CARRIER: *CLAIM HANDLER / TPA: *Adjuster’s Name: *Adjuster’s Mailing Address: *City: *Telephone: *Fax: D) *BRIEF DESCRIPTION of INJURY: CLAIM #: *State: *Zip: *Email: *Does Employer have 5 or more Employees? Yes No *How long has Employee worked for this Employer? Years *Does Employee still work for this Employer? Yes No *Did the Employee report injury to their Employer? Yes No *If Yes; on what date? To whom? Name: Position Title: *TN County of Injury: , or did the injury occur Out of State? If Yes, Which State? Months Unknown List names of witnesses to the injury, if any: E) *MEDICAL TREATMENT: Has the Employer provided a panel of at least three (3) approved physicians (or four for back injuries) to the Employee for selection? * Yes No If Yes, name physician selected from the panel:* *Name all doctors seen for this injury: *Has an approved physician placed the Employee on light duty work restrictions due to this injury? *Has an approved physician taken the Employee completely off work due to this injury? Yes *If “Yes” to either question, please give the doctor’s name: Yes No No REQUESTING PARTY I hereby request the Department of Labor and Workforce Development to assist in any disputed workers’ compensation issues related to the abovedetailed injury. I also authorize the Department of Labor and Workforce Development to contact any person who has information regarding that injury. If the requesting party is the Injured Employee or the Injured Employee’s legal representative, authorization is also given to the Department of Labor and Workforce Development to use the Injured Employee’s social security number in a manner necessary to provide the requested assistance. Further, by signature the requesting party or the party’s representative certifies that each of the above-detailed answers is true. 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. * BY CHECKING THE BOX AND SIGNING BELOW, THE REQUESTING PARTY CERTIFIES THAT A COMPLETED COPY OF THIS REQUEST FOR ASSISTANCE HAS BEEN FORWARDED TO THE OPPOSING PARTIES *PRINT NAME: *SIGNATURE: *DATE: LB-0381 (Revised 05/2012) Page 2 of 3 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 in Section A of the Request for Assistance (C40A 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/WORKERS’ COMPENSATION DIVISION State Office Bldg, 600W 540 McCallie Avenue Chattanooga, TN 37402-2066 Phone: 423-634-6422 Fax: 423-634-3115 TDLWD/WORKERS’ COMPENSATION DIVISION 1908 Bowater Drive Kingsport, TN 37660-4136 Phone: 423-224-2057 Fax: 423-224-2056 KNOXVILLE COOKEVILLE TDLWD/WORKERS’ COMPENSATION DIVISION 1610 University Avenue, 2nd Floor Knoxville, TN 37921-6741 Phone: 865-594-5177 Fax: 865-594-5172 TDLWD/WORKERS’ COMPENSATION DIVISION 410 Spring Street, Suite G Cookeville, TN 38501-3791 Phone: 931-520-4290 Fax: 931-520-4316 MURFREESBORO NASHVILLE TDLWD/WORKERS’ COMPENSATION DIVISION 845 Esther Lane Murfreesboro, TN 37129-5537 Phone: 615-848-6743 Fax: 615-217-9378 TDLWD/WORKERS’ COMPENSATION DIVISION 2222 Rosa L. Parks Boulevard Nashville, TN 37228-1306 Phone: 615-741-1383 Fax: 615-253-1223 JACKSON MEMPHIS TDLWD/WORKERS’ COMPENSATION DIVISION 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/WORKERS’ COMPENSATION DIVISION 170 North Main Street, 11th Floor Memphis, TN 38103-1820 Phone: 901-543-6077 Fax: 901-543-6039 LB-0381 (Revised 05/2012) Page 3 of 3 RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com