Free Form SD1 - Tennessee

STATE FILE #

SOCIAL SECURITY NO:

DATE OF INJURY:

SD1

WORKERS' COMPENSATION STATISTICAL DATA FORM

Revised 06-07 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 #

14. DATE OF BIRTH:

15. DATE OF HIRE:

16. EDUCATION LEVEL: LESS THAN 9TH GRADE SOME COLLEGE/ASSOC DEGREE BS/BA 17. ABLE TO RETURN TO PRIOR EMPLOYMENTS? YES NO 19. READ & WRITE AT 8TH GRADE LEVEL? YES
NO

SOME HIGH SCHOOL GED HIGH SCHOOL DIPLOMA GRADUATE/ PROFESSIONAL 18. REASONABLY TRANSFERRABLE JOB SKILLS? 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 32. RETURN TO WORK PAY WAS: LESS , SAME , HIGHER 31. DID EMPLOYEE RETURN TO WORK FOR SAME EMPLOYER? 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 26. WAS CLAIM DENIED? 41. DID INJURY RESULT IN DEATH? YES
NO IF YES, THEN LIST DATE OF BIRTH, AND RELATIONSHIP OF ALL DEPENDENTS:

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

STATE FILE #

SOCIAL SECURITY NO:

DATE OF INJURY:

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: (B) FIRST 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 (%) (G) TO BODY OR SPECIFIC MEMBER: (C) MI: (E) LICENSE NUMBER: MD DO DC (H) SCHEDULED MEMBER LOCATION LEFT RIGHT (D) TITLE:

(B) FIRST NAME (G) TO BODY OR SPECIFIC MEMBER:

(C) MI:

(E) LICENSE NUMBER: MD DO DC (H) SCHEDULED MEMBER LOCATION LEFT RIGHT

(D) TITLE:

(B) FIRST NAME (G) TO BODY OR SPECIFIC MEMBER:

(C) MI:

(E) LICENSE NUMBER: MD DO DC (H) SCHEDULED MEMBER LOCATION LEFT RIGHT

(D) TITLE:

EMPLOYEE'S VOCATIONAL EXPERT 67. (A) LAST NAME: (B) FIRST NAME EMPLOYER'S VOCATIONAL EXPERT 68. (A) LAST NAME: (B) FIRST NAME CHIROPRACTIC/PHYSICAL THERAPY 69. CHIROPRACTIC TREATMENT? YES NO IF YES, NUMBER OF VISITS?

(C) MI:

(D) TITLE:
PHD MA OTHER

(E) VOCATIONAL DISABILITY RATING:

(C) MI:

(D) TITLE:
PHD MA OTHER

(E) VOCATIONAL DISABILITY RATING:

70. PHYSICIAL THERAPY? YES NO IF YES, NUMBER OF VISITS?

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

VIII. SETTLEMENT TERMS
90. PPD%
YES NO TO BODY OR SPECIFIC MEMBER: LEFT RIGHT

IF YES, NUMBER OF WEEKS?

STATE FILE #

SOCIAL SECURITY NO:

DATE OF INJURY:

91. PTD?
YES NO

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

NO

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)?

IX. SECOND INJURY FUND
97. IS THIS A SECOND INJURY FUND CLAIM?
YES NO

98. WAS JUDGMENT ENTERED AGAINST SECOND INJURY FUND?
YES NO

99. APPORTIONMENT:

(1) EMPLOYER; ____ %; #WKS; __________TOTAL AMT.

(2) SECOND INJ FUND ____ %; #WKS; _________ TOTAL AMT.

X. MONETARY AMOUNTS PAID
TYPE OF BENEFIT PAID PRIOR TO TRIAL/ SETTLEMENT PAID PURSUANT TO TRIAL RESULTS PAID PURSUANT TO SETTLEMENT TERMS TOTAL PAYMENTS

100. TEMP TOTAL DISABILITY 101. TEMP PARTIAL DISABILITY 102. PERMANENT PARTIAL DISABILITY 103. PERMANENT TOTAL DISABILITY 104. DEATH BENEFITS 105. BURIAL EXPENSES 106. MEDICAL EXPENSES TOTAL (includes medicine, PT, chiro, hospital, MD/DO costs, tests) 107. CASE MANAGEMENT COSTS 108. DISCRETIONARY COSTS 109. AMOUNT PAID TO CLOSE FUTURE MEDICAL EXPENSE 110. LUMP SUM PAYMENT (not based on specific disability %) 111 DATE LUMP SUM PAID (not based on specific disability %): ______________________ 112. TOTALS (ADD TOTALS FROM LINES 100 THRU 110)

$0.00
$0.00
$0.00

$0.00

$0.00

$0.00
$0.00
$0.00

$0.00
$0.00

$0.00
$0.00
$0.00

$0.00

113. AMOUNT PAID IN LUMP SUM FROM LINES 100 THRU 105; _________________________
(DO NOT ADD THIS AMOUNT TO TOTAL PAYMENTS.
IT IS ALREADY INCLUDED IN THE TOTALS ABOVE.)

114. DATE LUMP SUM PAID FROM LINES 100 THRU 105 ___________________

XI. ATTORNEYS FEES
115. EMPLOYEE'S ATTORNEY FEE; AMOUNT OF AWARD ______________ 116. WAS FEE APPROVED BY COURT % OF AWARD __________ ; $1501-3000 ; $3000-$10,000
OR TDLWD

117. EMPLOYER'S ATTORNEY FEE (SPECIFY RANGE): UNDER $1500

; OVER $10,000

XII. CERTIFICATION AND SIGNATURES By providing my BPR number and my signature, I hereby certify that I have read the contents of the form and the information provided is true and correct to the best of my knowledge. ATTORNEY MUST PROVIDE BPR# .
118. NAME OF EMPLOYEE'S ATTORNEY: 120. NAME OF EMPLOYEE:
BPR#

119. NAME OF EMPLOYER'S ATTORNEY:

BPR#

121. NAME OF ADJUSTER/CARRIER/EMPLOYER REPRESENTATIVE:

SIGNATURE OF EMPLOYEE

DATE SIGNED

SIGNATURE OF ADJUSTER/CARRIER/EMPLOYER REP

DATE SIGNED

SIGNATURE OF EMPLOYEE'S ATTORNEY

DATE SIGNED

SIGNATURE OF EMPLOYER'S ATTORNEY

DATE SIGNED

LB 0904 (rev. 06-07)

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