Form Lb 0973 PDF Details

Form LB 0973 is a document used to report financial information for a business. This document is used by business owners and tax professionals to file taxes and track financial performance. The form can be completed online or offline, making it convenient for users. The instructions for filling out the form are clear and concise, making it easy to understand. Additionally, the form can be filled out in multiple languages, making it accessible to a wider audience. Overall, the LB 0973 form is an efficient and user-friendly way to track financial data for businesses of all sizes.

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

People who work with this document often make mistakes while filling out KINGSPORT TDLWDWC DIVISIONBENEFIT in this section. Remember to revise everything you enter here.

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