C40R
____________________________ RFA NUMBER ____________________________ STATE FILE NUMBER
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
CERTIFICATE OF READINESS FOR BENEFIT REVIEW CONFERENCE This Certificate is to be filed only if you have previously filed Form C40B Request for Benefit Review Conference Employee: _____________________________________________________ SS #: Email: ____________________________________
_______________________ Date of Injury: _______________ Employer: _______________________________________
Employee Counsel: _____________________________________________ Email : _______________________________________ Address: ______________________________ City: ______________________ State: _______________ Zip: __________________ Insurance: _____________________________ Claims Handler: _______________________ Email: __________________________ Address: ______________________________ City: ______________________ State: _______________ Zip: __________________ Employer Counsel: _____________________________________________ Email: ________________________________________ Address: ______________________________ City: ______________________ State: _______________ Zip: __________________ Is the Second Injury Fund involved with this claim? _____ Yes _____ No SIF Attorney ________________ The undersigned party or party's representative certifies each or the following to be true:
A request for Benefit Review conference has been or is being filed in this matter. An employee has reached Maximum Medical Improvement and an impairment rating has been given Date of MMI: _______________ Rating: __________________ Body Part: ___________________ All of the needed information regarding this claim has been exchanged with other parties and all parties agree that no additional discovery is needed. All parties have discussed dates for conducting mediation and the parties and/or their representatives have agreed on the dates listed below. Please Note: Dates are subject to availability.
The parties request that the BRC be scheduled on one of the following dates within the next 60 days. (circle one) ___________ 1st Choice 9:00 a.m. 1:00 p.m. (circle one) ___________ 2nd Choice 9:00 a.m. 1:00 p.m. (circle one) ___________ 3rd Choice 9:00 a.m. 1:00 p.m.
Name of Opposing Party Contact with whom dates for BRC were discussed: _________________________________________ Comments:__________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ___________________________________ Printed Name ___________________________________ Identify which Party or Representative)
LB-0973 (REV 6/09)
___________________________________ Signature
RDA 10183