Free TENNESSEE DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT - Tennessee

TENNESSEE DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT

Division of Workers' Compensation
REQUEST FOR SETTLEMENT APPROVAL
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 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. PART I (To be completed on all forms.) A) Date Of Injury: ____________________________________ B) State File #: ________________________________________ C) Injured Employee's Name: _________________________________________________________________________________ SSN: ____________________________________________ Date of Birth:_______________________________________ D) Was This Case Mediated By Tennessee Department of Labor & Workforce Development? Yes _____ No ____ ************************************************************************************************************ PART II (If there is a State File #, skip to Part III) E) Employee Information: Street Address: _______________________________________________________________________________________ City: __________________________________________ State: _____________________________ Zip: _____________ County: ________________________________________ Telephone: __________________________________________ Is Employee Represented by an Attorney?: _______________________________________________________________ Attorney's Name: _____________________________________________________________________________________ Mailing Address: _____________________________________________________________________________________ Telephone: ________________________________________ Fax: _____________________________________________ F) Employer's Name: _________________________________________________________________________________________ Street Address: _______________________________________________________________________________________ City: __________________________________________ State: ________________________ Zip: __________________ County: ________________________________________________ Telephone: __________________________________ G) Workers' Compensation Carrier Name: ______________________________________________________________________ Adjuster's Name: ____________________________________________ Telephone: ______________________________ Street Address: _______________________________________________________________________________________ City: ________________________________________ State: __________________________ Zip: __________________ Is Employer/Insurance Carrier Represented by Attorney? Yes _____ No _____ Attorney's Name: _____________________________________________________________________________________ Street Address: _______________________________________________________________________________________ City: _________________________________________ State: ______________________ Zip: _____________________ Telephone: __________________________________________ Fax: ___________________________________________ Part III (To be completed on all forms) Employee must be physically present for approval. Unless otherwise agreed, all approval reviews will be held in Department of Labor & Workforce Development Offices. Attach copy of proposed settlement, and supporting documentation. Date Requested for Settlement Review: ________________________________________________________________________ LB-0932 rev. 04/05