LB- (REV 2/18) RDA 1108 Tennessee 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 STATISTICAL DATA FORM FOR INJURIES ON/AFTER JULY 1, 2014Form SD-2 EMPLOYEE INFORMATION Docket # State File # Date of Injury Employee Last Name First Name MI Social Security # Date of Birth Education Level Less Than High SchoolHigh School of HireMore than High School CLAIM/INJURY INFORMATION Employer Is Employer Self-Insured?Yes No Is Employer a member of Drug Free Workplace Program? Yes No Insurer TPA Injury occurred in TN Yes No County of Injury First date out of work Date of return to work Total # of days lost Date of MMI ATP Impairment Rating % Average Weekly Wage Compensation Rate Was claim denied?Yes NoIf yes, basis of denial? Statute of LimitationsNotice Not Work-Related Vocational Assessment performed? Yes NoIntoxication/+ Drug Test Other (Specify) Nature of Primary Injury/Body Part Chiropractic Treatment?Yes No Occupational Illness? Yes No Physical Therapy?Yes Case Manager? Yes No Was there an Employee IME? Yes NoIf yes, Impairment Rating % Was there an Employer IME? Yes NoIf yes, Impairment Rating % SETTL E MENT / HEARING INFORMATION Type of Conclusion: Compensation HearingSettlement ApprovalIf yes, was dispute resolved in mediation?Yes No Was Bureau Mediation conducted?Yes NoIfconcluded by a Compensation Hearing:Date of Hearing Style of CaseName of Approving/Hearing Judge Date of Settlement Approval Impairment Rating % used to settle the claim Has Initial Compensation Period expired?YesNo If no, date this Period will expire PPD increased benefits awarded? Yes No Vocational Impairment for Increased Benefits If yes, check all that apply: Did not return to work 40+ years old Unemployment Rate Educationlevel there a trial for increased benefits?Yes No Was there a judgment for increased benefits? Yes No as there a judgment for the Employer?Yes If , what was the basis: Notice Not work related Statute of limitations No permanency Intoxication Willful Misconduct Other If yes, was return to work pay Higher Did Employee return to work for any Employer? Yes NoWas claim settled pursuant to T.C.A. 24750-6-240(e)?Yes No Same Less American LegalNet, Inc. www.FormsWorkFlow.com LB- (REV 2/18) RDA 1108 FUND INFORMATION Was there a judgment entered against the Subsequent Injury and Vocational Recovery Fund? Yes NoIf there was a judgment against the Subsequent Injury and Vocational Recovery Fund, how was the settlement apportioned? Employer % # of Weeks Subsequent Injury and Vocational Recovery Fund % # of Weeks MONETARY AMOUNTS PAID Temporary Total Disability # of weeks, or $ # of days Temporary Partial Disability # of weeks, or $ # of days Permanent Partial Disability PPD % # of weeks, or $ # of days Permanent Total Disability (including those to be paid) PTD % # of weeks, or $ # of days Increased P ermanent P artial D isability Benefits $ Death Benefits (including those to be paid) $ Burial Benefits $ Medical Benefits $ Future Medical Expenses Closure Date closed After prior settlement? Yes No $ Lump Sum per T.C.A. 24750 - 6 - 240(e) $ Total Paid for all above columns $ Amount of Settlement Paid in Lump Sum: $ (SSA requirement) (do not include this amount in total) Date Settlement Lump Sum Paid: Employee Attorney Fee $ % of Settlement Was fee approved by Court? Yes No Employer Attorney Fee Range Under $1,500 $1,501-$3,000 $3,001-$10,000 Over $10,000 CERTIFICATION AND SIGNATURES By providing my BPR Number and my signature, I hereby certify that I have read the contents of the form and the information provided is true and correct to the best of my knowledge. Printed name of Employee Signature Date BPR# Signature Date Printed name of Adjuster Signature Date BPR# Signature Date American LegalNet, Inc. www.FormsWorkFlow.com