TENNESSEE WORKERS’ COMPENSATION INSURANCE Employers: The law requires this notice to be conspicuously posted at the employer’s place of business so all employees have access to it. WHO IS REQUIRED TO HAVE WORKERS’ COMPENSATION INSURANCE? All employers with five (5) or more full or part-time employees. All employers engaged in the mining and production of coal with one (1) or more employees. All workers in the construction industry unless they are specifically exempted. To confirm if an employer is subject to the workers’ compensation law and if so to obtain the name of the workers’ compensation insurance company contact: __________________________________________________________________________________ Name of employer representative authorized to provide information on workers’ compensation __________________________________________________________________________________ Telephone number of employer representative to provide information on workers’ compensation __________________________________________________________________________________ Address of employer representative to provide information on workers’ compensation WHAT SHOULD AN EMPLOYEE DO IF INJURED AT WORK? 1. Report the injury to the employer immediately. Employer notification is required. and 2. Select a treating physician from a panel provided by the employer. To report an injury contact: __________________________________________________________________________________ Name of employer representative to notify in event of a work related injury __________________________________________________________________________________ Telephone number of employer representative to notify in event of a work related injury __________________________________________________________________________________ Address of employer representative to notify in event of a work related injury WHAT SHOULD AN EMPLOYER DO WHEN AN INJURY IS REPORTED? 1. and 2. Immediately complete a First Report of Work Injury form and send it to the workers’ compensation insurance company or the third party administrator to be filed with the Tennessee Dept. of Labor and Workforce Development, Workers’ Compensation Division. Offer a panel of physicians. The employer shall designate a group of three (3) or more physicians or surgeons not associated together in practice from which the injured employee shall have the privilege of selecting the operating surgeon or the attending physician. If the injury is a back injury, the panel shall be expanded to four (4), one of whom must be a doctor of chiropractic. If a doctor of chiropractic is chosen, chiropractor visits may be authorized for up to twelve (12) visits per back injury. More than twelve (12) visits to such doctor of chiropractic must be specifically approved by the employer or insurance carrier. The provisions for chiropractic care shall not apply to workers’ compensation self insurer pools established pursuant to Section 50-6-405(a)(1). If the injury requires the treatment of physician or surgeon who practices orthopedic or neuroscience medicine then the employer may appoint a panel of physicians or surgeons practicing orthopedic or neuroscience medicine consisting of five (5) physicians, with no more than four (4) physicians affiliated in practice together. The employee may select a treating physician or surgeon from the employer panel. The Tennessee Department of Labor and Workforce Development, Division of Workers’ Compensation, has staff available to help both employees and employers. For more information contact: TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF WORKERS’ COMPENSATION 220 FRENCH LANDING DRIVE NASHVILLE, TENNESSEE 37243-1002 615-532-4812 OR TOLL FREE 1-800-332-2667 OR 1-800-332-2257 (TDD) www.tn.gov/labor-wfd/wcomp.html LB-0922 (REV. 03/12) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com