Workers' Comp Forms

The Bureau has provided a comprehensive directory of all forms. Spanish versions are available where applicable.

Program Area	Name	Form Number	Spanish Equivalent
Adjuster Certification	Adjusting Entity Certification Application	LB-3266	N/A
Appeals Board	Affidavit of Indigency	LB-1108 LB-1108s	Declaración Jurada sobre Indigencia
Claims	Employee's Choice of Physician (Medical Panel)	C-42 LB-0382s	Selección de Médico por un Empleado
Claims	First Report of Injury	C-20 LB-0021	N/A
Claims	Notice of Change or Termination of Benefits	C-26 LB-0285	N/A
Claims	Notice of Denial	C-23	N/A
Claims	Notice of Employer Rights and Responsibilities
Claims	Notice of Primary Liaison
Claims	Notice of Reported Work Injury
Claims	Request For Prior Work Injury Information	LB-3271
Compliance	Employee Misclassification Tip	LB-0977s	Formulario de Informaci'on de Clasificaión Indebida del Empleado
Compliance	Request of Investigation	LB-0977 LB-0977s	Petición para Investigación
Court of Workers’ Compensation Claims	Notice of Appeal	LB-1099	Aviso de Apelación
Court of Workers’ Compensation Claims	Medical Record Certification	LB-1097	Certificación De Historial Médico Medical Record Certification
Court of Workers’ Compensation Claims	Request for Hearing Combined: Request for Expedited or Scheduling Hearing	LB-1098	Solicitud De Audiencia
Court of Workers’ Compensation Claims	Standard Form Medical Report	C-32	N/A
Court of Workers’ Compensation Claims	Subpoena	LB-0476	Citation--Subpoena
Court of Workers’ Compensation Claims	Petition for Benefits Determination - Settlement Only	LB-1120	N/A
Coverage	Reduction in Workforce Form I-3	LB-0286	N/A
Coverage	Sole Proprietor/Partner Selection Form I-4	LB-0228 LB-0228s	Aviso de Elección
Coverage	Sole Proprietor/Partner Withdrawal of Election Form I-5	LB-0287 LB-0287s	Aviso de Retiro
Coverage	Corporate Officer Election Not To Accept Form I-6	LB-0090	N/A
Coverage	Corporate Officer Withdrawal of Election Form I-7	LB-0288	N/A
Coverage	Exempt Employer Notice of Acceptance Form I-8	LB-0014 LB-0014s	Aviso de Aceptación
Coverage	Exempt Employer Withdrawal of Notice Form I-9	LB-0289 LB-0289s	Aviso de Retiro de Elección Voluntaria de Empleador Exento
Coverage	Notice of Waiver of Workers' Compensation Benefits for Specific Medical Conditions Forms I-10, I-11, I-12 (Combined Form) Heart, Epileptic or Occupational Disease	LB-0030 LB-0290s	Aviso de Exención
Coverage	Waiver Withdrawal Form I-13 Heart, Epileptic or Occupational Disease	LB-0290	N/A
Coverage	Common Carrier Election / Termination of Coverage Form I-14	LB-0300 LB-0300s	Selección de Compañía Común/Terminación de Cobertura
Coverage	Combined Form I-15 & I-17 General Contractor Acceptance / Termination of Coverage Agreement	LB-0301 LB-0301s	Aceptación de Contratista General
Coverage	Notice of Discontinuance Form I-18	N/A	N/A
Coverage	Posting Notice	LB-0922 LB-0922SP	Aviso de Seguro de Compensación de Trabajadores de Tennessee
EMEEF	Independent Contractor/Subcontractor
Mediation	Dispute Certification Notice	LB-1096	Aviso de Certificación de Disputa
Mediation	Request for Assistance Form / Mediation Form	C-40 LB-0381 LB-0381s	Solicitud para Mediación
Mediation	Request for Benefits from the UEF	LB-3284
Mediation	Wage Statement Form	C-41 LB-0384	N/A
Mediation	Permanent Total Disability Final Order Form	C-43 LB- 0988	N/A
Mediation	Request for Administrative Review of a WC Specialist's Order Form	C-44 LB-1016	N/A
Mediation	Petition for Benefits Determination (PBD)	LB 1095 LB-1095s	Petición para Determinación de Beneficios
Mediation	Certificate of Non-Representation (CNR)	LB-3252	Certificado de No Representación (CNR)
Medical	Drug-Free Workplace Program Application	LB-1111 LB-0977	Solicitud del Programa para Ambiente Laboral Libre de Drogas
Medical	Medical Waiver and Consent Form	C-31 LB-0379 LB-0379s	Consentimiento y Exención Médica
Medical	Case Management Notification	C-33 LB-1023	N/A
Medical	Case Management Closure	C-34 LB-0377	N/A
Medical	Utilization Review Notification Form	C-35 LB-0380	N/A
Medical	Notice of Appeal Rights for a Utilization Review Denial	C-35A LB-1023s	Aviso de derechos de apelación para una Revisión de Utilización
Medical	Utilization Review Closure Form	C-36 \| C-37 LB-0375	N/A
Medical	Case Management Registration Form	C-38 LB-0965	N/A
Medical	Provider Registration for Utilization Review Form	C-39 LB-0968	N/A
Medical	Medical Payment Committee Review Request Form	C-47 LB-1017	N/A
Medical	MIR Application for a Medical Impairment Rating	LB-0930 LB-0930s	Solicitud al Progama MIR para una Clasificación de Discapacidad Médica
Medical	MIR Application for Appointment to the Medical Impairment Rating Registry	LB-0928	N/A
Medical	MIR Impairment Rating Report - 5th Edition	LB-0931	N/A
Medical	MIR Impairment Rating Report - 6th Edition	LB-0931A	N/A
Medical	MIR Medical Waiver and Consent Form	LB-0929 LB-0929s	Denuncia y Consentimiento de Calificación de Discapacidad Médica
Medical	Final Medical Report Form	C-30A LB-0383	N/A
Medical	Physician Certification	LB-1109	N/A
Medical	Request for Expedited Determination - Appeal of a Denied Prescription	LB-1123	N/A
Settlement Approval	Request for Settlement Approval	LB-0932	N/A
Settlement Approval	SD-1 Statistical Data Form	LB-0904	N/A
Settlement Approval	SD-2 Statistical Data Form		N/A

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If you have additional questions, please call 615-532-4812 or 800-332-2667 or contact us by email at wc.info@tn.gov. Find out about other available assistance programs by contacting an ombudsman.

Workers' Comp Forms

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