| Name |
Division |
Form Number |
|---|
| Adjusting Entity Certification Application |
Workers' Compensation |
LB-3266 |
| Affidavit of Indigency |
Workers' Compensation |
LB-1108 |
| Affidavit of Indigency (Spanish) |
Workers' Compensation
|
LB-1108s |
| Amusement Accident Report |
Amusement Devices |
LB-3294
LB-3246 |
| Annual Inspection Report |
Amusement Devices |
LB-3300 |
| Application to Install Elevators |
Elevator Unit |
LB-0364 |
| Apply for a Repair/Erection License |
Boiler Unit |
LB-0386 |
| Boiler Inspection Variance Guide and Checklist |
Boiler Unit |
n/a |
| Boiler Installation Permit Application |
Boiler Unit |
LB-0936 |
| Certificate of Non-Representation (CNR) |
Workers' Compensation |
LB-3252 |
| Certificate of Non-Representation (CNR) (Spanish) |
Workers' Compensation |
LB-3252 |
| Combination of Application for Permit with Itinerary and Amusement Device List Form |
Amusement Devices |
LB-3298 |
| Dispute Certification Notice (DCN) |
Workers' Compensation |
LB-1096 |
| Dispute Certification Notice (Spanish) |
Workers' Compensation |
n/a |
| Drug-Free Workplace Form |
Workers' Compensation |
LB-0977 |
| Drug-Free Workplace Form (Spanish) |
Workers' Compensation |
LB-0977 |
| Employee Misclassification Tip Form |
Workers' Compensation |
LB-0977 |
| Employee Misclassification Tip Form (Spanish) |
Workers' Compensation |
LB-0977s |
| EMEEF Independent Contractor/Subcontractor List |
Workers' Compensation |
LB-3276 |
| Firefighter PTSD Grant Application |
Workers' Compensation |
n/a |
| Form C-20 | First Report of Injury |
Workers' Compensation |
LB-0021 |
| Form C-20 | TN First Report of Injury Form - Substitute for OSHA 301 |
TOSHA |
LB-0021 |
| Form C-22 | Notice of First Payment of Compensation |
Workers' Compensation |
LB-0024 |
| Form C-23 | Notice of Denial (Spanish) (Korean) |
Workers' Compensation |
LB-0283 |
| Form C-26 | Notice of Change or Termination of Benefits (Korean) |
Workers' Compensation |
LB-0285 |
| Form C-29 | Final Report of Payment |
Workers' Compensation |
LB-0020 |
| Form C-30a | Final Medical Report |
Workers' Compensation |
LB-0383 |
| Form C-31 | Medical Waiver and Consent (for injuries before 7/1/2014) |
Workers' Compensation |
LB-0379 |
| Form C-31sp | Medical Waiver and Consent (Spanish) (for injuries before 7/1/2014) |
Workers' Compensation |
LB-0379s |
| Form C-31B | Medical Waiver and Consent (for injuries on or after 7/1/2014) |
Workers' Compensation |
|
| Form C-31B_ES | Medical Waiver and Consent Spanish) (for injuries on or after 7/1/2014) |
Workers' Compensation |
|
| Form C-32 | Standard Form Medical Report |
Workers' Compensation |
LB-0369 |
| Form C-33 | Case Management Notification |
Workers' Compensation |
LB-0376 |
| Form C-34 | Case Management Closure Form |
Workers' Compensation |
LB-0377 |
| Form C-34 | Case Management Closure Instructions |
Workers' Compensation |
n/a |
| Form C-35 | Utilization Review Notification |
Workers' Compensation |
LB-0380 |
| Form C-35a | Utilization Review Denial Appeal |
Workers' Compensation |
LB-1023 |
| Form C-35a | Utilization Review Denial Appeal (Spanish) |
Workers' Compensation |
LB-1023s |
| Form C-36/C-37 | Utilization Review Closure |
Workers' Compensation |
LB-0375 |
| Form C-36/C-37 | Utilization Review Closure Form Completion Instructions |
Workers' Compensation |
n/a |
| Form C-38 | Case Management Registration |
Workers' Compensation |
LB-0965 |
| Form C-39 | Provider Registration for Utilization Review |
Workers' Compensation |
LB-0968 |
| Form C-40 | Request for Mediation (Spanish) |
Workers' Compensation |
LB-0381 |
| Form C-40 | Request for Mediation |
Workers' Compensation |
LB-0381 |
| Form C-41 | Wage Statement |
Workers' Compensation |
LB-0384 |
| Form C-42 | Agreement Between Employer/Employee Choice of Physician (Panel) (Spanish) (Korean) |
Workers' Compensation |
LB-0382 |
| Form C-43 | Permanent Total Disability Final Order |
Workers' Compensation |
LB- 0988 |
| Form C-44 | Request for Administrative Review of a WC Specialist's Order |
Workers' Compensation |
LB-1016 |
| Form C-47 | Medical Payment Committee Review Request |
Workers' Compensation |
LB-1017 |
| I-3 | Reduction in Workforce |
Workers' Compensation |
LB-0286 |
| I-4 | Sole Proprietor/Partner Selection / Notice of Election |
Workers' Compensation |
LB-0228 |
| I-4 | Aviso de Elección / Notice of Election |
Workers' Compensation |
LB-0228s |
| I-5 | Sole Proprietor/Partner Withdrawal of Election |
Workers' Compensation |
LB-0287 |
| I-5 | Aviso de Retiro / Notice of Withdrawal |
Workers' Compensation
|
LB-0287s |
| I-6 | Corporate Officer Election Not to Accept |
Workers' Compensation |
LB-0090 |
| I-7 | Corporate Officer Withdrawal of Election |
Workers' Compensation |
LB-0288 |
| I-8 | Exempt Employers Notice of Acceptance |
Workers' Compensation |
LB-0014 |
| I-8 | Exempt Employers Notice of Acceptance (Spanish) |
Workers' Compensation |
LB-0014s |
| I-9 | Exempt Employers Withdrawal of Notice |
Workers' Compensation |
LB-0289 |
| I-9 | Exempt Employers Withdrawal of Notice (Spanish) |
Workers' Compensation |
LB-0289s |
| I-10 | Notice of Waiver of Workers' Compensation Benefits for Specific Medical Conditions |
Workers' Compensation |
LB-0030 |
| I-10 | Notice of Waiver of Workers' Compensation Benefits for Specific Medical Conditions (Spanish) |
Workers' Compensation |
LB-0290s |
| I-13 | Waiver Withdrawal |
Workers' Compensation |
LB-0290 |
| I-14 | Common Carrier Election / Termination of Coverage Form |
Workers' Compensation |
LB-0300 |
| I-14 | Common Carrier Election / Termination of Coverage Form (Spanish) |
Workers' Compensation |
LB-0300s |
| I-15 | General Contractor Acceptance / Termination of Coverage Agreement Form |
Workers' Compensation |
LB-0301 |
| Job Order Transmittal |
Unemployment Insurance - Employers |
LB-0610 |
| Medical Record Certification |
Workers' Compensation |
LB-1097 |
| Medical Record Certification (Spanish) |
Workers' Compensation
|
LB-1097 |
| Request for Medical Impairment Rating (MIR) |
Workers' Compensation |
LB-0930 |
| Request for Medical Impairment Rating (MIR) (Spanish) |
Workers' Compensation |
LB-0930s |
| MIR Application for Appointment to the Medical Impairment Rating Registry |
Workers' Compensation |
LB-928A |
| CPP Application for Appointment to the Certified Physician Program Registry |
Workers' Compensation |
LB-928A |
| MIR Impairment Rating Report - 5th Edition |
Workers' Compensation |
LB-0931 |
| MIR Impairment Rating Report - 6th Edition |
Workers' Compensation |
LB-0931A |
| MIR Medical Waiver and Consent Form |
Workers' Compensation |
LB-0929 |
| MIR Medical Waiver and Consent Form (Spanish) |
Workers' Compensation |
LB-0929 |
| Notice of Demand for Examination |
Workers' Compensation
|
LB-201 |
| Notice of Employer Rights and Responsibilities |
Workers' Compensation |
LB-3265 |
| Workers' Compensation Notice of Appeal |
Workers' Compensation |
LB-1099 |
| Workers' Compensation Notice of Appeal (Spanish) |
Workers' Compensation
|
LB-1099 |
| Notice of Primary Liaison, Adjusters, and Bill Review Contacts (.xlsx) |
Workers' Compensation |
LB-3263 |
| Notice of Reported Work Injury (Spanish) (Korean) |
Workers' Compensation |
|
| Occupational Injury and Illness Record Keeping Forms |
TOSHA |
OSHA 300 |
| Occupational Injury and Illness Record Keeping Forms |
TOSHA |
OSHA 300A |
| Occupational Injury and Illness Record Keeping Forms |
TOSHA |
OSHA 301 |
| Parental Consent Form | Child Labor Laws |
Labor Standards |
LB-0355 |
| Petition for Benefit Determination (PBD) |
Workers' Compensation |
LB-1095 |
| Petition for Benefit Determination (Spanish) |
Workers' Compensation |
LB-1095 |
| Petition for Benefit Determination Settlement Approval Only |
Workers' Compensation |
LB-1120 |
| Addendum to PBD (for Death Claims Only) |
Workers' Compensation |
LB-1095-A |
Addendum to PBD (for Death Claims Only) (Spanish)
|
Workers' Compensation |
LB-1095-A |
| Addendum to PBD (for Multiple Employers Only) |
Workers' Compensation
|
|
| Addendum to PBD (for Multiple Employers Only) (Spanish) |
Workers' Compensation
|
|
| Physician Certification Form |
Workers' Compensation |
LB-1109 |
| Posting Notice (Spanish) (Korean) |
Workers' Compensation |
LB-0922 |
| Request for Benefits from the UEF |
Workers' Compensation |
LB-3284 |
| Request for Benefits from the UEF (Spanish / Bilingual) |
Workers' Compensation |
LB-3284 |
| Request for Consultative Services |
TOSHA |
LB-1010 |
| Request for Expedited Determination - Appeal of a Denied Prescription |
Workers' Compensation |
LB-1123 |
| Request for Translation of Document for WC Appeal |
Workers' Compensation |
|
| Request for Translation of Document for WC Appeal (Spanish) |
Workers' Compensation |
|
| Hearing Request |
Workers' Compensation |
LB-1098
|
| Hearing Request (Spanish) |
Workers' Compensation |
|
| Request for Investigation |
Workers' Compensation |
LB-0977 |
| Request for Investigation (Spanish) |
Workers' Compensation |
LB-0977s |
| Request For Prior Work Injury Information |
Workers' Compensation |
LB-3271 |
| Request for Settlement Approval (RSA) |
Workers' Compensation |
LB-0932 |
| Request for Tennessee High School Equivalency Verification, Transcript or Duplicate Diploma |
Adult Education |
n/a |
| SD1 Statistical Data Form |
Workers' Compensation |
LB 0904 |
| SD-2 Statistical Data Form |
Workers' Compensation |
|
| Separation Notice |
Unemployment Insurance - Employers |
LB-0489 |
| Subpoena |
Workers' Compensation |
LB-0476 |
| Subpoena (Spanish) |
Workers' Compensation
|
LB-0476 |
| Wage Complaint Form |
Workplace Regulations & Compliance (Labor Standards Unit) |
LB-0995 |