Form Lb 0922 PDF Details

In the state of Tennessee, the sphere of workers' compensation is a critical area of focus for both employers and employees, designed to assure that those injured on the job receive proper medical attention and financial support. The LB 0922 form, known as the Tennessee Workers’ Compensation Insurance Posting Notice, plays a fundamental role in this system. It outlines crucial steps to be taken by both parties in the event of a work-related injury, ensuring a streamlined process for reporting and addressing these incidents. The form mandates immediate reporting of the injury by the employee to a designated employer representative, along with the selection of a treating physician from an employer-provided panel. Concurrently, it obliges the employer to complete an internal "Workplace Injury form," notify their workers' compensation insurance company without delay, offer a panel of physicians to the employee, and, in emergencies, call an ambulance while providing this form once the employee is stable. Additionally, it lists contact details for the employer representative and alternative contacts, reinforcing the support system available to the injured worker. The Tennessee Bureau of Workers' Compensation, which is referenced for further assistance, underscores the comprehensive support structure aimed at safeguarding the well-being of Tennessee’s workforce. Mandating the posting of this notice in a visible location underscores the importance of transparency and readiness in addressing workplace injuries, adhering to the state's workers' compensation laws.

QuestionAnswer
Form NameForm Lb 0922
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namestennessee form lb 0922 template, 2020 lb 0922 fillable form, tennessee compensation, tn division workers compensation

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TENNESSEE WORKERS’ COMPENSATION INSURANCE

POSTING NOTICE

How to Report Work-Related Injuries

What should be done if injured at work?

Employee

1.Immediately report the injury to the employer representative named below.

2.Select a treating physician from a panel provided by your employer.

Employer

1.Complete your company’s internal “Workplace Injury form” and notify your workers’ compensation insurance company immediately, even if you have concerns about the validity of the claim.

3.If you have questions or problems, contact the employer representative or the Bureau of Workers’ Compensation.

2.Offer a panel of physicians to the employee via Form C-42 available on the

Bureau’s website. In cases of emergency, call an ambulance and provide this form as soon as the injured employee has stabilized.

___________________________________________________________________________________

Printed name and title of the employer representative to be notified in the event of a work-related injury

___________________________________________________________________________________

Printed name of an alternative employer representative to be notified in the event of a work-related injury

___________________________________________________________________________________

Telephone number of employer representative to notify in event of a work-related injury

___________________________________________________________________________________

Address of employer representative to notify in event of a work-related injury

The Tennessee Bureau of

220 French Landing Dr. 1-B

Nashville, TN 37243-2667

Workers’ Compensation is

800-332-2667

available to help both

employees and employers.

615-532-4812 TTD: 800-332-2257

 

tn.gov/workerscomp

Workers’ Compensation law requires this notice to be posted in a conspicuous place at the work site at all times.

LB-0922 (REV. 4/18)

Authorization No. 337545

RDA 10183