Workers' Comp Forms

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

Program Area	Name	Form Number
Adjuster Certification	Adjusting Entity Certification Application	LB-3266
Appeals Board	Affidavit of Indigency (Spanish)	LB-1108 LB-1108s
Appeals Board	Request for Translation of Document (Spanish)
Claims	Employee's Choice of Physician (Medical Panel) (Spanish) (Korean)	C-42 LB-0382s
Claims	First Report of Injury	C-20 LB-0021
Claims	Notice of Change or Termination of Benefits (Korean)	C-26 LB-0285
Claims	Notice of Denial (Spanish) (Korean)	C-23
Claims	Notice of Employer Rights and Responsibilities
Claims	Notice of Primary Liaison
Claims	Notice of Reported Work Injury (Spanish) (Korean)
Claims	Request For Prior Work Injury Information	LB-3271
Compliance	Employee Misclassification Tip (Spanish)	LB-0977s
Compliance	Request for Investigation (Spanish)	LB-3304
Court of Workers’ Compensation Claims	Notice of Appeal (Spanish)	LB-1099
Court of Workers’ Compensation Claims	Medical Record Certification (Spanish)	LB-1097
Court of Workers’ Compensation Claims	Hearing Request (Spanish) Combined: Request for Expedited or Scheduling Hearing	LB-1098
Court of Workers’ Compensation Claims	Standard Form Medical Report	C-32
Court of Workers’ Compensation Claims	Subpoena (Spanish)	LB-0476
Court of Workers’ Compensation Claims	Petition for Benefits Determination - Settlement Only	LB-1120
Court of Workers’ Compensation Claims	Addendum to PBD (for Death Claims Only) (Spanish)	LB-1095-A
Court of Workers’ Compensation Claims	Addendum to PBD (for Multiple Employers Only) (Spanish)
Court of Workers’ Compensation Claims	Notice of Demand for Examination	LB-201
Coverage	Reduction in Workforce Form I-3	LB-0286
Coverage	Sole Proprietor/Partner Selection Form I-4 (Spanish)	LB-0228 LB-0228s
Coverage	Sole Proprietor/Partner Withdrawal of Election Form I-5 (Spanish)	LB-0287 LB-0287s
Coverage	Corporate Officer Election Not To Accept Form I-6	LB-0090
Coverage	Corporate Officer Withdrawal of Election Form I-7	LB-0288
Coverage	Exempt Employer Notice of Acceptance Form I-8 (Spanish)	LB-0014 LB-0014s
Coverage	Exempt Employer Withdrawal of Notice Form I-9 (Spanish)	LB-0289 LB-0289s
Coverage	Notice of Waiver of Workers' Compensation Benefits for Specific Medical Conditions Forms I-10, I-11, I-12 (Spanish) (Combined Form) Heart, Epileptic or Occupational Disease	LB-0030 LB-0290s
Coverage	Waiver Withdrawal Form I-13 Heart, Epileptic or Occupational Disease	LB-0290
Coverage	Common Carrier Election / Termination of Coverage Form I-14 (Spanish)	LB-0300 LB-0300s
Coverage	Combined Form I-15 & I-17 General Contractor Acceptance / Termination of Coverage Agreement (Spanish)	LB-0301 LB-0301s
Coverage	Notice of Discontinuance Form I-18	N/A
Coverage	Posting Notice (Spanish) (Korean)	LB-0922 LB-0922SP
EMEEF	Independent Contractor/Subcontractor
Mediation	Dispute Certification Notice (DCN) (Spanish)	LB-1096
Mediation	Request for Assistance Form / Mediation Form (Spanish)	C-40 LB-0381 LB-0381s
Mediation	Request for Benefits from the UEF	LB-3284
Mediation	Wage Statement Form	C-41 LB-0384
Mediation	Permanent Total Disability Final Order Form	C-43 LB- 0988
Mediation	Request for Administrative Review of a WC Specialist's Order Form	C-44 LB-1016
Mediation	Petition for Benefits Determination (PBD) (Spanish)	LB 1095 LB-1095s
Mediation	Certificate of Non-Representation (CNR) (Spanish)	LB-3252
Medical	Drug-Free Workplace Program Application (Spanish)	LB-1111
Medical	Medical Waiver and Consent Form (Spanish)	C-31 LB-0379 LB-0379s
Medical	Case Management Notification	C-33 LB-0376
Medical	Case Management Closure	C-34 LB-0377
Medical	Utilization Review Notification Form	C-35 LB-0380
Medical	Notice of Appeal Rights for a Utilization Review Denial (Spanish)	C-35A LB-1023s
Medical	Utilization Review Closure Form (Instructions)	C-36 \| C-37 LB-0375
Medical	Case Management Registration Form	C-38 LB-0965
Medical	Provider Registration for Utilization Review Form	C-39 LB-0968
Medical	Medical Payment Committee Review Request Form	C-47 LB-1017
Medical	Request for Medical Impairment Rating (MIR) (Spanish)	LB-0930 LB-0930s
Medical	Application for Appointment to the Medical Impairment Rating (MIR) Registry	LB-0928
Medical	Application for Appointment to the Certified Physician Program (CPP) Registry	LB-0928
Medical	MIR Impairment Rating Report - 5th Edition	LB-0931
Medical	MIR Impairment Rating Report - 6th Edition	LB-0931A
Medical	MIR Medical Waiver and Consent Form (Spanish)	LB-0929 LB-0929s
Medical	Final Medical Report Form	C-30A LB-0383
Medical	Physician Certification	LB-1109
Medical	Request for Expedited Determination - Appeal of a Denied Prescription	LB-1123
Settlement Approval	Request for Settlement Approval (RSA)	LB-0932
Settlement Approval	SD-1 Statistical Data Form	LB-0904
Settlement Approval	SD-2 Statistical Data Form	LB-3261

Need More Help?

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.