Workers' Comp Forms

Program Area   Name   Form Number   Spanish Equivalent  

Appeals Board

Affidavit of Indigency LB-1108
LB-1108s
Declaración Jurada sobre Indigencia

Claims

Agreement Between Employer/Employee Choice of Physician C-42
LB-0382s
Selección de Médico por un Empleado

Claims

Agreement Between Employer/Employee Choice of Physician - Government C-42 N/A

Compliance

Employee MIsclassification Tip LB-0977s Formulario de Informaci'on de Clasificaión Indebida del Empleado
Compliance Request for Investigation  LB-0977
LB-0977s
Petición para Investigación

Court of Workers’ Compensation Claims

Compensation Hearing Notice of Appeal LB-1103 

N/A

Court of Workers’ Compensation Claims

Expedited Hearing Notice of Appeal LB-1099   

N/A

Court of Workers’ Compensation Claims

Medical Record Certification LB-1097

N/A

Court of Workers’ Compensation Claims

Request for Expedited Hearing LB-1100   

N/A

Court of Workers’ Compensation Claims

Request for Scheduling Hearing LB-1098

N/A

Court of Workers’ Compensation Claims

Standard Form Medical Report C-32

N/A

Court of Workers’ Compensation Claims

Subpoena

 LB-0476 

N/A

Coverage

Certificate of Insurer Form I-1 LB-0043 N/A

Coverage

Notice of Cancelation Form I-2 LB-0004 N/A

Coverage

Reduction in Workforce Form I-3 LB-0286 N/A

Coverage

Sole Proprietor/Partner Selection Form I-4 LB-0228
LB-0228s
Aviso de Elección

Coverage

Sole Proprietor/Partner Withdrawal of Election Form I-5 LB-0287
LB-0287s
Aviso de Retiro

Coverage

Corporate Officer Election Not To Accept Form I-6 LB-0090 N/A

Coverage

Corporate Officer Withdrawal of Election Form I-7 LB-0288 N/A

Coverage

Exempt Employer Notice of Acceptance Form I-8 LB-0014
LB-0014s
Aviso de Aceptación

Coverage

Exempt Employer Withdrawal of Notice Form I-9 LB-0289
LB-0289s
Aviso de Retiro de Elección Voluntaria de Empleador Exento

Coverage

Notice of Waiver of Workers' Compensation Benefits for Specific Medical Conditions I-10 LB-0030
LB-0290s 
Aviso de Exención

Coverage

Waiver Withdrawal Form I-13 LB-0290 N/A

Coverage

Common Carrier Election / Termination of Coverage Form  I-14 LB-0300
LB-0300s
Selección de Compañía Común/Terminación de Cobertura

Coverage

General Contractor Acceptance / Termination of Coverage Agreement Form I-15 LB-0301
LB-0301s
Aceptación de Contratista General

Coverage

Notice of Discontinuance Form I-18 N/A N/A

Coverage

Posting Notice LB-0922
LB-0922SP
Aviso de Seguro de Compensación de Trabajadores de Tennessee

Mediation

Dispute Certification Notice LB-1096  Aviso de Certificación de Disputa

Mediation

Request for Assistance Form / Mediation Form C-40
LB-0381
LB-0381s
Solicitud para Mediación

Mediation

Wage Statement Form  C-41
LB-0384
N/A

Mediation

Permanent Total Disability Final Order Form  C-43
LB- 0988 
N/A

Mediation

Request for Administrative Review of a WC Specialist's Order Form  C-44
LB-1016 
N/A

Mediation

Petition for Benefits Determination LB 1095 
LB-0381s
Petición para Determinación de Beneficios

Medical

Drug Free Workplace Program Application    LB-1111
LB-0977
Solicitud del Programa para Ambiente Laboral Libre de Drogas

Medical

Medical Waiver and Consent Form  C-31
LB-0379
LB-0379s
Consentimiento y Exención Médica

Medical

Case Management Notification C-33
LB-1023
N/A

Medical

Case Management Instructions C-34 N/A

Medical

Case Management Closure C-34
LB-0377
N/A

Medical

Utilization Review Notification Form  C-35
LB-0380
N/A

Medical

Notice of Appeal Rights for a Utilization Review Denial C-35A
LB-1023s
Aviso de derechos de apelación para una Revisión de Utilización

Medical

Utilization Review Closure Form  C-36 | C-37
LB-0375
N/A

Medical

Case Management Registration Form  C-38
LB-0965
N/A

Medical

Provider Registration for Utilization Review Form  C-39
LB-0968
N/A

Medical

Medical Payment Committee Review Request Form  C-47
LB-1017
N/A

Medical

MIR Application for a Medical Impairment Rating LB-0930
LB-0930s
Solicitud al Progama MIR para una Clasificación de Discapacidad Médica

Medical

MIR Application for Appointment to the Medical Impairment Rating Registry LB-0928 N/A

Medical

MIR Impairment Rating Report - 5th Edition LB-0931 N/A

Medical

MIR Impairment Rating Report - 6th Edition LB-0931A N/A

Medical

MIR Medical Waiver and Consent Form LB-0929
LB-0929s
Denuncia y Consentimiento de Calificación de Discapacidad Médica

Medical

Final Medical Report Form  C-30A
LB-0383 
N/A

Medical

Physician Certification LB-1109 N/A

Medical

Request for Expedited Determination - Appeal of a Denied Prescription LB-1123 N/A

Medical

Case Management Notification C-33
LB-1023
N/A

Medical

Case Management Closure C-34
LB-0377
N/A

Settlement Approval

Request for Settlement Approval LB-0932 N/A

Settlement Approval

SD-1 Statistical Data Form LB-0904 N/A

Court of Workers’ Compensation Claims

Petition for Benefits Determination - Settlement Only LB-1120 N/A

Need More Help?

If you have additional questions, please call 615-532-4812 or 800-332-2667 or contact us by email at wc.info@tn.gov. Find out about other available assistance programs by contacting an ombudsman