Statistical Data Form

Docket Number: Enter the Docket Number assigned by the Court of Workers’ Compensation Claims.

State File Number: Enter the State File Number assigned to the C20.

Date of Injury: Use mm/dd/yyyy. Match the DOI on the C20, Court Order, and SD2.

SSN: Prefer use of the full SSN, may submit last 4 digits.

Date of Birth: Use mm/dd/yyyy for the injured worker.

Date of Hire: Use mm/dd/yyyy for the injured worker. This is often on the C20 or the employer will know this date.

Education Level: Use employment application, resume, or contact the injured worker to obtain this information.

Employer/Insurance/TPA: Match the name submitted on the C20.

Injury occurred in TN: Mark yes or no.

County of injury: See C20 or ask the injured worker to obtain this information. Enter the Tennessee County or “Out of State” if it occurred outside of Tennessee.

First Date out of work: Use mm/dd/yyyy. Use the single date the injured worker first missed work. Use N/A if injured worker did not miss work.

Date of return to work: Use mm/dd/yyyy representing the single, most recent date of the injured worker’s final return to any work (light duty if applicable) with the pre-injury employer. Use “did not return to work” if PTD or if injured worker chose not to return to work, if applicable or N/A if the injured worker did not miss work. Match the SD2 and the settlement agreement.

Total # days lost: Enter the total number missed workdays between the DOI and MMI, whether compensated or not.

Date of MMI: List the final MMI date. Use N/A if MMI has not been reached.

ATP % Impairment rating: List the combined whole person rating assigned by the authorized treating physician. Use N/A if no rating is assigned.

Average weekly wage, Comp rate: Enter the average weekly wage used to determine the injured workers’ compensation rate. Use the permanent disability rate. View the benefit rate chart.

Was claim denied, if so basis of denial: Match the SD2 with the C23 Notice of Denial filed with the Bureau.

Nature of Primary Injury/Body Part Injured: Check these lists and choose the one that most closely represents the injury and body part for the claim. Enter the number and the description. (Injured workers won’t understand the number alone.)

Was Bureau mediation conducted: Mark yes if a PBD was previously filed for temporary disability, medical or permanent disability benefits disputes

Did employee return to work for any employer: Mark yes if the injured worker is working for the pre-injury employer or if he/she is working for a different employer at the time of the workers’ compensation settlement hearing.

Indicate if the injured worker’s current wages are the same, higher, or less when compared to their average weekly wage.

Was claim settled pursuant to TCA 50-6-240(e): Mark yes if the claim settled on a doubtful/disputed basis.

The SD2 dollar amounts must match the subject settlement agreement.

TTD: Enter the number of weeks and/or days and dollar amount paid using the appropriate temporary disability calculations. Match the subject settlement agreement. Use N/A if injured worker did not receive TTD benefits.

TPD: Enter the number of weeks and/or full days represented by the dollar amount paid using the appropriate temporary disability calculations. Match the subject settlement agreement. Use N/A if injured worker did not receive TPD benefits.

PPD: Enter the disability percentage, number of weeks and/or days and the dollar amount paid representing the original award. (Impairment x comp rate x 450). Match the subject settlement agreement. Use N/A if injured worker did not receive PPD benefits.

PTD: Enter the number of weeks and the dollar amount paid using the appropriate permanent disability calculations. Use the dollar amount paid and the disability percentage represented by that dollar amount. Match the settlement agreement. Use N/A if injured worker did not receive PTD benefits.

Increased Perm. Partial Benefits: This field represents the resulting award and additional factors. It equals the total payment less the original award.

Mark the fields titled “PBD Increased Benefits Awarded” and indicate which factors applied on the 1st page of the SD2. Use N/A if injured worker did not receive increased benefits.

Death Benefits: Include lump sum, accrued benefits and estimate the total sum to be paid based upon the agreement, expected eligibility termination dates, if applicable, or assume the dependent(s) will qualify until the benefit is exhausted. Use N/A if injured worker did not receive death benefits.

Burial Benefits: Enter the dollar amount paid for funeral expense and burial. Use N/A if injured worker did not receive burial benefits.

Medical Benefits: Enter the dollar amount paid for all medical expenses up to the point of original settlement. No need to add anticipated medical expenses on settlements that may be paid after the original settlement. The adjusters report the additional medical expenses paid in a yearly filing to the Bureau.

Future Medical Expense Closure; Date Closed: Enter the date of the settlement if the future medical expenses are being closed with current settlement. Include the money paid specifically to close medicals, including on doubtful and disputed settlements. Use format mm/dd/yyyy for the date medical benefits are closed.

After prior settlement: Mark yes if the medicals were left open in a prior settlement and are now being closed in a subsequent settlement. Otherwise mark no.

Lump Sum per TCA 50-6-240 (e): Enter the dollar amounts paid in a doubtful/disputed settlement.

Amount of settlement paid in lump sum: Enter the dollar amount paid in lump sum for the current settlement. Match the lump sum figure in the agreement.

Date lump sum paid: Use the actual date mm/dd/yyyy the employee receives the payment.

Sometimes the SD2 is filed before the employee receives the payment. In this event, use the language stated in the settlement agreement specifying when the employee will receive the payment. This is commonly the 14th calendar day from the date of the settlement hearing.

Employee attorney fee: Enter the dollar amount and percentage of the settlement paid to the employee attorney for the current settlement.

Was fee approved by Court: This is pertaining to the employee’s attorney fee. Yes should be marked if the fees are in the agreement and the presiding Judge signed the order. Match the SD2 with the settlement documents.

Employer’s attorney fee range: Mark the category that best fits the fee.

Clearly print or type the name of each party. The signatures of all attorneys and the injured worker, the date each signed, and BPR numbers are required. Include the adjuster’s name, even if he or she does not sign the form.

Injury Codes