STATE FILE # SOCIAL SECURITY NO: DATE OF INJURY: FORM SD1 Revised 12-07 WORKERS' COMPENSATION STATISTICAL DATA FORM Page 1 of 3 Fraud Warning. 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. This area for Department use only. THIS FORM MUST BE FILED WITH THE CLERK OF THE COURT This area for Court use only. CONTEMPORANEOUSLY WITH THE FINAL ORDER IN ALL WORKERS' COMPENSATION CASES IN WHICH THE COURT EITHER TRIES THE CASE OR APPROVES A SETTLEMENT. FOR SETTLEMENTS SUBMITTED TO THE DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT FOR APPROVAL, SUBMIT THIS FORM WITH THE APPROVAL REQUEST. NEITHER THE ORDER OF THE COURT NOR THE DEPARTMENT'S APPROVAL IS FINAL UNTIL THIS FORM IS FULLY COMPLETED AND FILED WITH THE APPROPRIATE ENTITY. [STATUTORY AUTHORITY: TCA 50-6-244(b), (d)] I. EMPLOYEE INFORMATION 1. STATE FILE #: 4. FIRST NAME: 7. ADDRESS: 2. SOCIAL SECURITY NO: 5. MIDDLE INITIAL: 8. CITY: 3. DATE OF INJURY: 6. LAST NAME: 9. STATE: 10. ZIP: 11. COUNTY & STATE OF RESIDENCE AT CONCLUSION OF CASE COUNTY: STATE: 12. COUNTY & STATE OF RESIDENCE AT TIME OF INJURY: COUNTY: STATE: 13. INSURER FILE #: 16. EDUCATION LEVEL: SOME COLLEGE/ASSOC DEGREE 17. ABLE TO RETURN TO PRIOR EMPLOYMENTS? YES 14. DATE OF BIRTH: LESS THAN 9TH GRADE NO 15. DATE OF HIRE: SOME HIGH SCHOOL GED HIGH SCHOOL DIPLOMA GRADUATE/ PROFESSIONAL 18. REASONABLY TRANSFERRABLE JOB SKILLS? YES NO 19. READ & WRITE AT 8TH GRADE LEVEL? YES NO II. CLAIM/INJURY INFORMATION 20. INJURY OCCURRED: IN TN OUT OF STATE 21.TN COUNTY OF INJURY: 22. AVERAGE WEEKLY WAGE: 23. WEEKLY COMP RATE 24. NATURE OF PRIMARY INJURY/ILLNESS: 25. BODY PART: 27. IF "YES" TO 26, STATE BASIS OF DENIAL: STATUTE OF LIMITATIONS , NOTICE , NOT WORK RELATED , YES NO INTOXICATED/POSITIVE DRUG TEST , OTHER, SPECIFY, 29. WAS PSYCHOLOGICAL INJURY CLAIMED? 30. WAS PSYCHOLOGICAL INJURY SOLE CLAIM? 28. WAS SURGERY PERFORMED? YES NO YES NO YES NO 31. DID EMPLOYEE RETURN TO WORK FOR SAME EMPLOYER? 32. RETURN TO WORK PAY WAS: LESS , SAME , HIGHER YES NO 33. DATE OF FIRST TTD PAYMENT: 34. FIRST DATE OUT OF WORK: 35. FINAL RETURN TO WORK DATE: 36. TOTAL NUMBER OF DAYS LOST: 37. MMI DATE: 38. DATE RETURNED TO WORK BY PHYSICIAN: 39. IS EMPLOYEE CURRENTLY EMPLOYED? YES NO 40. IS EMPLOYEE CURRENTLY RECEIVING SOCIAL SECURITY DISABILITY? YES NO 41. DID INJURY RESULT IN DEATH? YES NO IF YES, THEN LIST DATE OF BIRTH, AND RELATIONSHIP OF ALL DEPENDENTS: 26. WAS CLAIM DENIED? 42. CLAIMS ADMINISTRATOR OR TPA FIRM NAME: (If Different From Insurance Carrier) 44. ADDRESS: 48. NAME OF CASE MGMT PROVIDER: 45. CITY: 43. CLAIMS ADM/TPA FEIN: 46. STATE: 47. ZIP: III. EMPLOYER INFORMATION 49. EMPLOYER NAME: (not parent co., DBA where injured employee works) 51. ADDRESS: 52. CITY: NO 50. FEIN: 53. STATE: 54. ZIP: 55. DID EMPLOYER HAVE A CERTIFIED DRUG FREE WORKPLACE PROGRAM? YES 56. IF SELF INSURED, NAME OF SELF INSURED PROGRAM 57. SELF INSURED PROGRAM FEIN Pg 1 of 3 LB-0904 (REV. 12-07) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com STATE FILE # SOCIAL SECURITY NO: DATE OF INJURY: FORM SD1 58. NAME OF INSURANCE CARRIER: 59. INSURANCE CARRIER FEIN: 60. ADDRESS: 61. CITY: 62. STATE: 63. ZIP: IV. MEDICAL AND VOCATIONAL EXPERTS NAMES OF TREATING PHYSICIANS 64. (A) LAST NAME: (F) IMPAIRMENT RATING (%) (A) LAST NAME: (F) IMPAIRMENT RATING (%) EMPLOYEE'S IME(s) 65. (A) LAST NAME: (F) IMPAIRMENT RATING (%) EMPLOYER'S IME(s) 66. (A) LAST NAME: (F) IMPAIRMENT RATING (%) EMPLOYEE'S VOCATIONAL EXPERT 67. (A) LAST NAME: EMPLOYER'S VOCATIONAL EXPERT 68. (A) LAST NAME: (B) FIRST (C) MI: (D) TITLE: (E) LICENSE NUMBER: NAME: (G) TO BODY OR SPECIFIC MEMBER: MD DO DC (H) SCHEDULED MEMBER LOCATION LEFT RIGHT (B) FIRST (C) MI: (D) TITLE: (E) LICENSE NUMBER: NAME: (G) TO BODY OR SPECIFIC MEMBER: MD DO DC (H) SCHEDULED MEMBER LOCATION LEFT RIGHT (B) FIRST (C) MI: (D) TITLE: (E) LICENSE NUMBER: NAME: (G) TO BODY OR SPECIFIC MEMBER: MD DO DC (H) SCHEDULED MEMBER LOCATION LEFT RIGHT (B) FIRST (C) MI: (D) TITLE: (E) LICENSE NUMBER: NAME: (G) TO BODY OR SPECIFIC MEMBER: MD DO DC (H) SCHEDULED MEMBER LOCATION LEFT RIGHT (B) FIRST NAME: (C) MI: (D) TITLE: PHD MA OTHER (E) VOCATIONAL DISABILITY RATING: (B) FIRST NAME: (C) MI: (D) TITLE: PHD MA OTHER (E) VOCATIONAL DISABILITY RATING: CHIROPRACTIC/PHYSICAL THERAPY 69. CHIROPRACTIC TREATMENT? YES NO IF YES, NUMBER OF VISITS? 70. PHYSICIAL THERAPY? YES IF YES, NUMBER OF VISITS? NO V. TYPE OF CONCLUSION AND COURT IDENTIFICATION INFORMATION TRIAL (Applicable only when the case has been TRIED by the court.) SETTLEMENT APPROVED BY COURT -COMPLAINT FILED (Applicable only when a lawsuit has been initiated by the filing of a complaint and summons.) SETTLEMENT APPROVED BY COURT - COMPLAINT NOT FILED. (Applicable only when a lawsuit has NOT been initiated by the filing of a complaint ­ term "joint petition" used to refer to this type of procedure for purposes of this form.) 71. STYLE OF CASE: 73. COUNTY: 76. DATE COMPLAINT FILED: 79. DATE OF SETTLEMENT APPROVAL: 74. COURT: 77. DATE OF TRIAL: 72. COURT DOCKET NO: 75. FULL NAME OF TRIAL JUDGE/CHANCELLOR: 78. DATE JOINT PETITION FILED: 80. NAME OF APPROVING JUDGE/CHANCELLOR SETTLEMENT APPROVED BY DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT (Applicable only when the approval is by the Department.) 81. DATE OF SETTLEMENT APPROVAL BY SPECIALIST: 82. NAME OF SPECIALIST APPROVING SETTLEMENT: VI. BENEFIT REVIEW CONFERENCE 83. DATE OF CONFERENCE: 84. SETTLED? YES NO 85. NAME OF SPECIALIST: VII. TRIAL RESULTS 86. PPD% YES YES NO NO TO BODY OR SPECIFIC MEMBER: LEFT NO RIGHT IF YES, NUMBER OF WEEKS? 88. DEATH CLAIM? YES IF YES, NUMBER OF WEEKS? ; NOT WORK RELATED ; 87. PTD? 89. JUDGMENT FOR EMPLOYER? YES NO , SELECT BASIS: STATUE OF LIMITATIONS ; NOTICE NO PERMANENCY ; INTOXICATION ; WILLFUL MISCONDUCT ; OTHER, SPECIFY Pg 2 of 3 LB-0904 (REV. 12-07) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com STATE FILE # SOCIAL SECURITY NO: DATE OF INJURY: FORM SD1 VIII. SETTLEMENT TERMS 90. PPD% YES YES NO NO TO BODY OR SPECIFIC MEMBER: LEFT NO RIGHT IF YES, NUMBER OF WEEKS? 92. DEATH CLAIM? YES IF YES, NUMBER OF WEEKS? ; OPEN FOR LIFE ; OR, OPEN FOR A SPECIFIED PERIOD? 95. DATE MEDICALS WERE OR WILL BE CLOSED: YES NO 91. PTD? 93. FUTURE MEDICAL EXPENSE: CLOSED 94. WAS MONEY PAID TO CLOSE FUTURE MEDICALS? YES NO 96. WAS CASE SETTLED PURSUANT TO TCA 50-6-206(b)? I