FORM C40A TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers’ Compensation 2222 Rosa L. Parks Blvd. Nashville, Tennessee 37228 Toll Free: 1-800-332-2667 FAX: 615-253-1223 or 615-253-2479 RFA NUMBER STATE FILE NUMBER REQUEST FOR ASSISTANCE Failure To Complete All Items On This Form Will Cause Delay In Processing And May Result In The Form Being Returned To The Requesting Party. For assistance in completing this form call 1-800-332-2667. 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. A) DATE OF INJURY: ________________________________________ B) ASSISTANCE IS REQUESTED FOR: (Check all that apply) Temporary Disability Benefits: ___________ Medical Care Benefits: _______________ Penalty for late payment or non-payment of benefits: ________ Discovery: C) INJURED EMPLOYEE’S NAME: _____________________________________________________ SSN: _____________________________ Date of Birth: _________________________ Street Address: ___________________________________________________________ City: ______________________________ State: __________ Zip: _________________ County:____________________________ Phone: ______________________________ Email Address: ___________________________________________________________ Is Employee Represented By An Attorney? _____________________________________ Attorney’s Name: _________________________________________________________ Mailing Address: __________________________________________________________ Telephone: ________________________ Fax: _________________________________ Email Address: ___________________________________________________________ D) EMPLOYER’S NAME:______________________________________________________ Street Address: ___________________________________________________________ City: ______________________________ State: __________ Zip: _________________ County: ___________________________ Telephone: ___________________________ Email Address: ___________________________________________________________ Is Employer Represented By An Attorney? _____________________________________ Attorney’s Name: _________________________________________________________ Mailing Address: __________________________________________________________ Telephone: ________________________ Fax: _________________________________ Email Address: ___________________________________________________________ Do Five Or More Employees Work For Employer? ________________________________ LB-0381 (REV. 04/09) Pg 1 of 2 RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com FORM C40A E) WORKERS’ COMPENSATION INSURANCE COMPANY: Company Name: __________________________________________________________ Street Address: ___________________________________________________________ City: ______________________________ State: __________ Zip: _________________ Adjuster’s Name: __________________________________________________________ Telephone: __________________________ Fax: _____________________________ Email Address: ___________________________________________________________ F) BRIEF DESCRIPTION OF INJURY: Nature of Injury (carpal tunnel, broken arm, etc.)__________________________________ How injury occurred (fell, lifting, driving, etc.) ____________________________________ ________________________________________________________________________ When did Employee report injury to employer? __________________________________ To Whom? _________________________ Person’s Title: _________________________ How long has Employee worked for employer? __________________________________ County of Injury: __________________________________________________________ G) MEDICAL TREATMENT: Was Employee given a choice of three (3) or more treating doctors? _________________ If a panel was provided, which doctor was selected? _____________________________ (Please attach all relevant records resulting from medical treatment for this injury. Failure to do so may result in resolution of your request being delayed.) H) DESCRIBE COMPLAINT OR REASON FOR REQUEST: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ For faster service, you may send your completed form directly to the local office that will handle your request. You can find a map of the offices along with addressees and phone numbers by checking our website at http://www.state.tn.us/labor-wfd/wc_map.pdf I hereby request the Department of Labor and Workforce Development to assist in any disputed workers’ compensation issues related to the above-detailed injury. I also authorize the Department of Labor and Workforce Development to contact any person who has information regarding that injury. If the undersigned 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 any manner necessary to provide the requested assistance. ____________________________________________ DATE: ___________________________ SIGNATURE OF REQUESTING PARTY _____________________________________ PRINTED NAME OF REQUESTING PARTY REQUEST FOR ASSISTANCE form must be signed by Requesting party or authorized representative. LB-0381 (REV. 04/09) Pg 2 of 2 RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com