Free FORM C40B - Tennessee

FORM C40B

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation http://www.state.tn.us/labor-wfd/wcomp.html Toll Free: 1-800-332-2667

____________________________ RFA NUMBER ____________________________ STATE FILE NUMBER

REQUEST FOR BENEFIT REVIEW CONFERENCE
A) DATE OF INJURY: ________________________________ B) This REQUEST is FOR: (Please indicate ONE purpose only) ________ ________ ________ ________ ________

Mediation, New Injury; Employee has reached Maximum Medical Improvement and parties request a BRC A signed and fully completed Form C40R including mutually agreeable Conference dates has been attached. Reconsideration; State File # of initial request: __________________ Date of Injury: __________________ Statute of limitation purposes; the Employee has reached Maximum Medical Improvement. A C40R will be submitted once parties are prepared to proceed with a Benefit Review Conference. Statute of limitation purposes; the Employee has NOT reached Maximum Medical Improvement. A C40R will be submitted once parties are prepared to proceed with a Benefit Review Conference Request for Discovery

C) Is Second Injury Fund involved? ____ Yes ____ No (If Yes, Attorney Name: __________________________________)
To preserve claim against the SIF, you must send a copy of this form to the Administrator of Workers' Compensation, Second Injury Fund, at 220 French Landing Drive, Nashville TN 37243 or by fax to (615) 741- 4169.)

REQUESTING PARTY MUST SEND A COPY OF THIS REQUEST TO ALL PARTIES
D) INJURED EMPLOYEE'S NAME: _____________________________________________________________________ SSN: ______________________________________ Date of Birth: __________________________________________ Street Address: ______________________________________________________________________________________ City: _________________________________________ State: ___________________________ Zip: ________________ County:_________________ Telephone: _________________________ Email: ________________________________ Is Employee Represented By An Attorney? _______________ Attorney's Name: ____________________________________________________________ BPR# _________________ Mailing Address: _________________________________ City _______________ State ____________ Zip __________ Telephone: _________________________ Fax: _______________________ Email: ______________________________ E) EMPLOYER'S NAME: ______________________________________________________________________________ Street Address: _______________________________________________________________________________________ City: ____________________________ State: ______________ Zip: _______________ County: ____________________ Telephone: _________________________ Fax: ___________________________ Email: ___________________________ Do Five Or More Employees Work For Employer? ______________ Is Employer Represented By An Attorney? ______________ Attorney's Name: ___________________________________________________________ BPR# ___________________ Mailing Address: _____________________________________________________________________________________ Telephone: _________________________ Fax: _______________________ Email: _______________________________
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F)

WORKER'S COMPENSATION INSURANCE COMPANY NAME: ________________________________________ Adjuster's Name: _________________________ Street Address: ______________________________________________ City: _________________________________State: ____________________________ Zip: ________________________ Telephone: ________________________Fax: __________________________ Email: ______________________________

G) BRIEF DESCRIPTION OF INJURY: Nature of Injury (carpal tunnel, broken arm, etc.)____________________________________________________________ How injury occurred (fell, lifting, driving, etc.) _____________________________________________________________ Date Employee reported injury to employer? _______________________________________________________________ To Whom? ______________________________________ Person's Title: _______________________________________ How long has Employee worked for employer? _________________________County of Injury: _____________________ H) MEDICAL TREATMENT: Was Employee given a panel of at least three (3) doctors to choose from? ________________________________________ List the names of all doctors seen: ________________________________________________________________________

I will complete and submit a Certificate of Readiness (Form C40 R) after the claimant reaches Maximum Medical Improvement (MMI). In addition all requests for discovery have been exchanged with all parities. If claimant has reached MMI, a Certificate of Readiness has been completed and is attached to this request.
____________________________________________________ PRINTED NAME OF REQUESTING PARTY _____________________________________________________ SIGNATURE OF REQUESTING PARTY AREA OFFICE LOCATIONS Phone: (800) 332-2667
NASHVILLE: 2222 METROCENTER BLVD, NASHVILLE TN 37228 FAX: (615) 253-1223 JACKSON: 225 DR. MARTIN L, KING JR. DRIVE, 1ST FLOOR, SUITE 120, BOX 26, JACKSON TN, 38301 FAX: (731) 265-7022 Fax: (731) 423-5679 KNOXVILLE: 1610 UNIVERSITY AVE., 2ND FLOOR KNOXVILLE, TENNESSEE 37921 FAX: (865) 594-5172 MURFREESBORO: 845 ESTER LANE MURFREESBORO, TENNESSEE 37129-5537 FAX: (615) 217-9378 CLARKSVILLE: 350 PAGEANT LANE, SUITE 406 CLARKSVILLE, TENNESSEE 37040-8606 FAX: (931) 221-4971 COOKEVILLE: 410 SPRING STREET, SUITE G COOKEVILLE, TENNESSEE 38501-3791 FAX: (931) 520-4316
Failure To Complete All Items On This Form Will Cause Delay In Processing And May Result In The Form Being Returned To The Requesting Party. For assistance in completing this form call 1-800-332-2667. 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.

_________________________________________ DATE

DYERSBURG: 412 WEST COURT STREET, DYERSBURG, TN 38024 FAX: (731) 286-8285 KINGSPORT: 1908 BOWATER DRIVE, KINGSPORT TN 37660 FAX: (423) 224-2056 MEMPHIS: 170 NORTH MAIN STREET, 11TH FLOOR MEMPHIS, TENNESSEE 38103-1820 FAX: (901) 543-6039 CHATTANOOGA: STATE OFFICE BUILDING, W600 540 WEST MCCALLIE AVENUE CHATTANOOGA, TENNESSEE 37402-2066 FAX: (423) 634-3115 COLUMBIA: 230 E. JAMES CAMPBELL BLVD., SUITE 113 COLUMBIA, TENNESSEE 38401-4597 FAX: (931) 380-2525

LB0974 (REV 6/09)

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RDA 10183