REQUEST FOR BENEFIT REVIEW CONFERENCE SF # STAMP-DATE RECEIVED TENNESSEE DEPT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers’ Compensation RFA # http://www.tn.gov/labor-wfd/wcomp.html Toll Free Help Line: 1-800-332-2667 PLEASE NOTE: ALL FIELDS MARKED WITH AN ASTERISK *ARE MANDATORY Failure to complete the required information on this form will result in the form being returned to the requesting party for completion. A) * THIS REQUEST is FOR: (Please indicate ONE purpose only.) Mediation; Employee has reached Maximum Medical Improvement and parties are ready to proceed to Benefit Review Conference. (A completed Certificate of Readiness – C40R Form is attached.) Statute of Limitations purposes; the Employee has reached Maximum Medical Improvement, but parties are not ready to proceed. (A completed C40R Form shall be submitted once parties are fully prepared to mediate this claim.) Statute of Limitations purposes; the Employee has not reached Maximum Medical Improvement. (A completed C40R Form shall be submitted once parties are fully prepared to mediate this claim.) Reconsideration of previous settlement under State File #: Date of Injury: *Is the Second Injury Fund involved in the Settlement of this Claim? Yes B) No Unknown If yes, Please name SIF ATTORNEY: To preserve a claim against the SIF, you must fax a copy of this form to TDL&WD Legal Office fax number 615-741-4169 or mail a copy to: Legal Services Director, TDL&WD Legal Section, 220 French Landing Drive, 3B, Nashville, TN 37243. *SOCIAL SECURITY # *EMPLOYEE’S NAME: *Mailing Address: *City: *County of Residence: * DATE of INJURY * DATE of BIRTH C) * State: *Telephone: * Zip: Email: *If the Employee is represented by an attorney, all fields in this section are mandatory. EE’s ATTORNEY: BPR#: Mailing Address: City: State: Telephone: D) *EMPLOYER’S NAME: *Mailing Address: * City: *Telephone: LB-0974 (Revised 05/2012) Fax: Zip: Email: *Contact: State: *Fax: Zip: *Email: Page 1 of 3 RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com *If the Employer is represented by an attorney, all fields in this section are also mandatory. ER’s ATTORNEY: BPR#: Mailing Address: City: State: Telephone: *INSURANCE CARRIER: *CLAIM HANDLER: *Adjuster’s Name: *Adjuster’s Mailing Address: *City: *Telephone: Fax: Zip: Email: E) F) *CLAIM#: *State: *Email: *Fax: *Zip: *BRIEF DESCRIPTION of INJURY: *County of Injury: *This Employee worked for this Employer: Years *Please give a brief explanation of the disputed issues: *Did the Employee return to work for the same Employer? Yes No Months *Does Employee still work for this Employer? Yes No G) MEDICAL TREATMENT: *Did the Employee receive payment of Temporary Disability Benefits? Yes No *Was there an impairment rating assigned by the Authorized Treating Physician? Yes *Was there an impairment rating assigned by an Independent Medical Examination? Yes *Was there an impairment rating assigned through the Medical Impairment Rating Registry? No No Yes No Submitting this form and attaching all pertinent medical information and relevant documents to the other parties as well as this Division will help to expedite the Benefit Review process. 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 BENEFIT REVIEW CONFERENCE HAS BEEN FORWARDED TO THE OPPOSING PARTIES *PRINT NAME: *SIGNATURE: *DATE: LB-0974 (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 C of the Request for Benefit Review Conference (C40B 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-0974 (Revised 05/2012) Page 3 of 3 RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com