Form Lb 0973 PDF Details

The LB-0973 form serves as an essential document within the Tennessee Department of Labor & Workforce Development's Division of Workers' Compensation. This Certificate of Readiness formalizes the progression of a workers' compensation claim towards resolution, signaling that all preliminary requirements have been met for a case to advance. It comes into play after the initial Request for Benefit Review Conference (BRC) – Form C40B is filed and outlines critical milestones reached in the claim process, including the employee having attained Maximum Medical Improvement (MMI), the assignment of a permanent impairment rating, and the establishment of a weekly compensation rate. The form mandates full disclosure and agreement on the necessity of further discovery and confirms the scheduling readiness for mediation by listing potential dates and times. Filled with contact information for all involved parties, the LB-0973 form ensures transparent communication lines. Moreover, the document highlights a collaborative agreement between the claimant, employer, and, if applicable, the Second Injury Fund Attorney, aiming to facilitate a smoother resolution process. Through this document, all parties affirm their commitment to moving forward with mediation, evidenced by the signatures of the employee or their representative and the employer or their representative, thus marking a significant step towards finalizing the workers' compensation claim.

QuestionAnswer
Form NameForm Lb 0973
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesc40r certificate of readiness tennessee form

Form Preview Example

STAMP- DATE RECEIVED

CERTIFICATE OF READINESS

TENNESSEE DEPT OF LABOR & WORKFORCE DEVELOPMENT

Division of Workers’ Compensation

http://www.tn.gov/labor-wfd/wcomp.html

Toll Free Help Line: 1-800-332-2667

SF #

RFA #

*

*

*

This Certificate is to be filed ONLY if the Request for Benefit Review Conference –Form C40B was previously filed.

The BRC will not be scheduled if information marked by asterisks on this form is missing.

Date of Injury: Employee’s Social Security Number:

A Request for Benefit Review Conference in this matter was previously filed with the Division on

The Employee has reached Maximum Medical Improvement and a permanent impairment rating has been given.

MMI Date:

 

Impairment Rating:

 

Body Part:

 

 

 

 

 

 

 

 

 

 

*

*

*

All information regarding this claim has been exchanged between the parties or their representatives and ALL agree that no additional discovery is necessary. This includes any IME or MIRR ratings.

The weekly compensation rate has been established. YES

NO

 

 

 

If applicable, the Second Injury Fund Attorney is

 

 

 

 

and has been notified.

 

The Parties have discussed possible dates for conducting the mediation and ALL parties or their representatives have agreed upon the three dates and times listed below. (Circle Desired Time Slot)

*

 

*

 

 

*

 

 

 

9:00am / 1:00 pm

 

 

 

9:00am / 1:00 pm

 

 

9:00am / 1:00 pm

 

 

 

 

*CONTACT INFORMATION

 

 

Employee

Address

City State Zip

Ph# Fax#

E-Mail

EE’s Atty

Address

City State Zip

Ph# Fax#

E-Mail

Employer

Address

City State Zip

Ph# Fax#

E-Mail

ER’s Atty

Address

City State Zip

Ph# Fax#

E-Mail

Ins. Carrier/Self-Insured Employer:

Address City State Zip

Adjuster Name:

Ph# Fax# E-Mail

By signing below, the Requesting party or party’s representative certifies all the above information to be true:

*

Employee or Employee’s Representative (Print Name)

*

Employee or Employee’s Representative (Signature)

*

Employer or Employer’s Representative (Print Name)

*

Employer or Employer’s Representative (Signature)

LB-0973 (Revised 12/2013)

Page 1 of 2

RDA 10183

TENNESSEE DEPT OF LABOR & WORKFORCE DEVELOPMENT

Division of Workers’ Compensation

http://www.tn.gov/labor-wfd/wcomp.html

Toll Free Help Line: 1-800-332-2667

Please return the completed form to the office listed below that is

closest to the home address of the Employee named on the Certificate of Readiness-C40R form.

If you need help in completing this form, please call the office nearest you

or our toll-free help line listed above.

CHATTANOOGA

TDLWD/WC DIVISION-BENEFIT REVIEW

State Office Bldg, 600W

540 McCallie Avenue

Chattanooga, TN 37402-2066

Phone: 423-634-6422

Fax: 423-634-3115

KNOXVILLE

TDLWD/WC DIVISION-BENEFIT REVIEW

1525 University Avenue, Suite 100

Knoxville, TN 37921-6741

Phone: 865-594-5177

Fax: 865-594-5172

MURFREESBORO

TDLWD/WC DIVISION-BENEFIT REVIEW

845 Esther Lane

Murfreesboro, TN 37129-5537

Phone: 615-848-6743

Fax: 615-217-9378

JACKSON

TDLWD/WC DIVISION-BENEFIT REVIEW

225 Dr. Martin L. King Jr. Drive

1st Floor, Suite 120, Box 26

Jackson, TN 38301-6985

Phone: 731-423-5646

Fax: 731-265-7022

KINGSPORT

TDLWD/WC DIVISION-BENEFIT REVIEW

1908 Bowater Drive

Kingsport, TN 37660-4136

Phone: 423-224-2057

Fax: 423-224-2056

COOKEVILLE

TDLWD/WC DIVISION-BENEFIT REVIEW

444– A Neal Street Cookeville, TN 38501-4027 Phone: 931-520-4290 Fax: 931-520-4316

NASHVILLE

TDLWD/WC DIVISION-BENEFIT REVIEW

220 French Landing Dr.

Nashville, TN 37243

Phone: 615-741-1383

Fax: 615-253-1223

MEMPHIS

TDLWD/WC DIVISION-BENEFIT REVIEW

170North Main Street, 11th Floor Memphis, TN 38103-1820 Phone: 901-543-6077

Fax: 901-543-6039

LB-0973 Revised 12/2013)

Page 2 of 2

RDA 10183

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Form Lb 0973 conclusion process outlined (part 1)

2. Once your current task is complete, take the next step – fill out all of these fields - TENNESSEE DEPT OF LABOR WORKFORCE, Division of Workers Compensation, httpwwwtngovlaborwfdwcomphtml, Toll Free Help Line, Please return the completed form, closest to the home address of the, If you need help in completing, or our tollfree help line listed, CHATTANOOGA TDLWDWC, KINGSPORT TDLWDWC DIVISIONBENEFIT, and COOKEVILLE TDLWDWC DIVISIONBENEFIT with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Writing section 2 in Form Lb 0973

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