REQUEST FOR SETTLEMENT APPROVAL 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 RSA # PLEASE NOTE: ALL SECTIONS MARKED WITH AN ASTERISK * ARE MANDATORY A)* DATE of INJURY *Employee's Social Security Number: Yes No Yes Yes No No If Yes, Date of Initial Settlement If Yes, Date of Initial Settlement B)*Was This Case Mediated By Tennessee Dept of Labor & Workforce Development? C)*Does This Settlement Represent the Closure of Medical Coverage? D)*Does this Settlement Represent the Reconsideration of Prior Settlement? E)*EMPLOYEE'S NAME: MAILING ADDRESS: CITY: EMPLOYEE'S ATTORNEY: PHONE #: FAX #: DATE of BIRTH STATE: ZIP: BPR#: EMAIL: Contact Person: BPR#: F)*EMPLOYER'S NAME: EMPLOYER'S ATTORNEY: PHONE #: FAX #: EMAIL: G)*INSURANCE CARRIER: CLAIM HANDLER: ADJUSTER'S NAME: PHONE #: FAX #: EMAIL: CLAIM #: DATES REQUESTED for APPROVAL: The Employee must be physically present for the Approval Session. Unless otherwise agreed, all Approval sessions will be held in Department of Labor & Workforce Development Offices BY SIGNATURE BELOW, THE PARTIES REQUEST THAT THE TENNESSEE DEPARTMENT OF LABOR REVIEW AND APPROVE THE PROPOSED SETTLEMENT AGREEMENT, HEREBY SUBMITTED ALONG WITH ALL SUPPORTING DOCUMENTS. * Employee or Employee's Representative (Signature) * Employer or Employer's Representative (Signature) CONFIRMED DATE of SCHEDULED APPROVAL SESSION LB-0932 (Revised 03/2012 Page 1 of 2 RDA10183 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 E of the Request for Settlement Approval (RSA form) or 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 TDLWD/WORKERS' COMPENSATION DIVISION State Office Bldg, 600W 540 McCallie Avenue Chattanooga, TN 37402-2066 Phone: 423-634-6422 Fax: 423-634-3115 KNOXVILLE TDLWD/WORKERS' COMPENSATION DIVISION 1610 University Avenue, 2nd Floor Knoxville, TN 37921-6741 Phone: 865-594-5177 Fax: 865-594-5172 KINGSPORT TDLWD/WORKERS' COMPENSATION DIVISION 1908 Bowater Drive Kingsport, TN 37660-4136 Phone: 423-224-2057 Fax: 423-224-2056 COOKEVILLE TDLWD/WORKERS' COMPENSATION DIVISION 410 Spring Street, Suite G Cookeville, TN 38501-3791 Phone: 931-520-4290 Fax: 931-520-4316 MURFREESBORO TDLWD/WORKERS' COMPENSATION DIVISION 845 Esther Lane Murfreesboro, TN 37129-5537 Phone: 615-848-6743 Fax: 615-217-9378 NASHVILLE TDLWD/WORKERS' COMPENSATION DIVISION 2222 Rosa L. Parks Boulevard Nashville, TN 37228-1306 Phone: 615-741-1383 Fax: 615-253-1223 JACKSON 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 MEMPHIS TDLWD/WORKERS' COMPENSATION DIVISION 170 North Main Street, 11th Floor Memphis, TN 38103-1820 Phone: 901-543-6077 Fax: 901-543-6039 LB-0932 (Revised 03/2012 Page 2 of 2 RDA10183 American LegalNet, Inc. www.FormsWorkFlow.com