LB-0932 (Revised 03/2012) Page 1 of 2 RDA10183 REQUEST FOR SETTLEMENT APPROVAL 226 FORM RSA TENNESSEE BUREAU OF WORKERS222 COMPENSATION http://www.tn.gov/labor-wfd/wcomp.html Toll Free Help Line: 1-800-332-2667 PLEASE NOTE: ALL SECTIONS MARKED WITH AN ASTERISK * ARE MANDATORY A)* DATE of INJURY// B)*Was this case mediated by the TN Bureau of Workers222 Compensation? Yes No C)*does this settlement represent the closure of medical coverage? Yes No D)*does this settlement represent the reconsideration of a prior settlement? Yes No E)*EMPLOYEE222S NAME: DATE of BIRTH / / EMPLOYEE222S ATTORNEY: BPR#: PHONE # FAX # EMAIL: F)*EMPLOYER222S NAME: Contact Person: EMPLOYER222S ATTORNEY: BPR#: PHONE # FAX # EMAIL: G)*INSURANCE CARRIER: CLAIM HANDLER: CLAIM # ADJUSTER222S NAME: PHONE # FAX # EMAIL: The Employee must be physically present for the Approval Session. Unless otherwise agreed, all Approval sessions will be held in TN Bureau of Workers222 Compensation Offices. * * Employee or Employee222s Representative (Signature) Employer or Employer222s Representative (Signature) DATE of SCHEDULED APPROVAL SESSION STAMP-DATE RECEIVED SF # RSA # FOR OFFICE USE ONLY BY SIGNATURE BELOW, THE PARTIES REQUEST THAT THE TN BUREAU OF WORKERS222 COMPENATION REVIEW AND APPROVE THE PROPOSED SETTLEMENT AGREEMENT, HEREBY SUBMITTED ALONG WITH ALL SUPPORTING DOCUMENTS. American LegalNet, Inc. www.FormsWorkFlow.com LB-0932 (Revised 03/2012) Page 2 of 2 RDA10183 TENNESSEE BUREAU OF WORKERS222 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 the Request for Settlement Approval (RSA form) or the Request for Mediation (C40B form). If you need help in completing this form, please call the office nearest you or our toll-free help line listed above. American LegalNet, Inc. www.FormsWorkFlow.com