- Employer's First Report of Injury or Occupational Disease - Alabama
- Employer's First Report of Injury or Disease - Wisconsin
- Worker's Report of Injury - Arizona
- Workers' Compensation Claim Form - California
- Workers Compensation Inclusion/Exclusion Form - Minnesota
- Workers' Compensation Commission Application for Ajustment Claim - Illinois
Fillable Printable Compensation Hearing Notice of Appeal - Tennessee
Fillable Printable Compensation Hearing Notice of Appeal - Tennessee
![Compensation Hearing Notice of Appeal - Tennessee](/resources/formfile/images/10000/compensation-hearing-notice-of-appeal-tennessee-page1.png)
Compensation Hearing Notice of Appeal - Tennessee
![](/resources/formfile/htmls/10000/compensation-hearing-notice-of-appeal-tennessee/bg1.png)
Filed Date Stamp Here
COMPENSATION HEARING NOTICE OF APPEAL
Tennessee Division of Workers’ Compensation
www.tn.gov/labor-wfd/wcomp.shtml
wc.courtclerk@tn.gov
1-800-332-2667
Docket #: _______________________
State File #/YR: __________________
RFA #: __________________________
Date of Injury: ___________________
SSN: ___________________________
Employee
Employer and Carrier
Notice
Notice is given that
[List name(s) of all appealing party(ies) on separate sheet if necessary]
appeals the order(s) of the Court of Workers’ Compensation Claims at ______
to the Workers’ Compensation Appeals Board.
[List the date(s) the order(s) was filed in the court clerk’s office]
Judge
Statement of the Issues
Provide a short and plain statement of the issues on appeal or basis for relief on appeal:
List of Parties
Appellant (Requesting Party): ___At Hearing: ☐Employer ☐Employee
Address:
Party’s Phone: Email:
Attorney’s Name: BPR#:
Attorney’s Address: Phone:
Attorney’s City, State & Zip code:
Attorney’s Email:
* Attach an additional sheet for each additional Appellant *
RDA 11082
LB-1103 rev. 4/15
Page 1 of 2
![](/resources/formfile/htmls/10000/compensation-hearing-notice-of-appeal-tennessee/bg2.png)
Employee Name: ____________________________________ SF#: ________________________________ DOI: __________________
Appellee(s)
Appellee (Opposing Party):____________________At Hearing: ☐Employer ☐Employee
Appellee’s Ad
dress: ____
Appellee’s Phone: Email: ____
Attorney’s Name: BPR#: _
Attorney’s Address: Phone: _
Attorney’s City, State & Zip code: __________________ _________ ______
Attorney’s Email: _
* Attach an additional sheet for each additional Appellee *
CERTIFICATE OF SERVICE
I,
, certify that I have forwarded a true and exact copy of this
Compensation Hearing Notice of Appeal by First Class, United States Mail, postage prepaid, to all parties
and/or their attorneys in this case in accordance with Rule 0800-02-22.01(2) of the Tennessee Rules of
Board of Workers’ Compensation Appeals on this the
___day of , 20__.
[Signa
ture of appellant or attorney for appellant]
Attention:
This form should only be used when filing an appeal to the Workers’ Compensation Appeals
Board. If you wish to appeal a case to the Tennessee Supreme Court, please utilize the form provided by
the Court which can be found on their website at the following address:
http://www.tncourts.gov/sites/default/files/docs/notice_of_appeal_-_civil_or_criminal.pdf
LB-1103 rev. 4/15
Page 2 of 2
RDA 11082