Fillable Printable Compensation Hearing Notice of Appeal - Tennessee

Compensation Hearing Notice of Appeal - Tennessee

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

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

, 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