Form Sd1 – Fill Out and Use This PDF

This area for Department use only.

THIS FORM MUST BE FILED WITH THE CLERK OF THE COURT This area for Court use only.

CONTEMPORANEOUSLY WITH THE FINAL ORDER IN ALL

WORKERS’ COMPENSATION CASES IN WHICH THE COURT

EITHER TRIES THE CASE OR APPROVES A SETTLEMENT. FOR

1.

STATE FILE #:

2. SOCIAL SECURITY NO:

3.

DATE OF INJURY:

4.

FIRST NAME:

5.

MIDDLE INITIAL:

6.

LAST NAME:

7.

ADDRESS:

8.

CITY:

9. STATE:

10. ZIP:

11. COUNTY & STATE OF RESIDENCE AT CONCLUSION OF CASE

12. COUNTY & STATE OF RESIDENCE AT TIME OF INJURY:

COUNTY:

STATE:

COUNTY:

STATE:

13. INSURER FILE #:

14. DATE OF BIRTH:

15. DATE OF HIRE:

20. INJURY OCCURRED: IN TN

OUT OF STATE

21.TN COUNTY

22. AVERAGE WEEKLY

23. WEEKLY COMP RATE

OF INJURY:

WAGE:

24. NATURE OF PRIMARY INJURY/ILLNESS:

25.

BODY PART:

26.

WAS CLAIM DENIED?

27. IF “YES” TO 26, STATE BASIS OF DENIAL: STATUTE OF LIMITATIONS

, NOTICE

, NOT WORK RELATED ,

YES

NO

INTOXICATED/POSITIVE DRUG TEST

, OTHER, SPECIFY,

28. WAS SURGERY PERFORMED?

29. WAS PSYCHOLOGICAL INJURY CLAIMED?

30. WAS PSYCHOLOGICAL INJURY SOLE CLAIM?

YES

NO

YES

NO

YES

NO

31.

DID EMPLOYEE RETURN TO WORK FOR SAME EMPLOYER?

32. RETURN TO WORK PAY WAS: LESS

, SAME

, HIGHER

YES

NO

33.

DATE OF FIRST TTD PAYMENT:

34. FIRST DATE OUT OF WORK:

35. FINAL RETURN TO WORK DATE:

36. TOTAL NUMBER OF DAYS

LOST:

37.

MMI DATE:

38. DATE RETURNED TO WORK BY PHYSICIAN:

39. IS EMPLOYEE CURRENTLY EMPLOYED?

YES

NO

40. IS EMPLOYEE CURRENTLY RECEIVING SOCIAL SECURITY DISABILITY?

YES

NO

41.

DID INJURY RESULT IN DEATH? YES

NO

IF YES, THEN LIST DATE OF BIRTH, AND RELATIONSHIP OF ALL DEPENDENTS:

42.

CLAIMS ADMINISTRATOR OR TPA FIRM NAME: (If Different From Insurance Carrier)

43. CLAIMS ADM/TPA FEIN:

44.

ADDRESS:

45. CITY:

46. STATE:

47. ZIP:

48.

NAME OF CASE MGMT PROVIDER:

49. EMPLOYER NAME: (not parent co., DBA where injured employee works)

50. FEIN:

51. ADDRESS:

52. CITY:

53. STATE:

54. ZIP:

55. DID EMPLOYER HAVE A CERTIFIED DRUG FREE WORKPLACE PROGRAM? YES

NO

56. IF SELF INSURED, NAME OF SELF INSURED PROGRAM

57. SELF INSURED PROGRAM FEIN

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64.

(A) LAST NAME:

(B) FIRST

(C) MI:

(D) TITLE:

(E) LICENSE NUMBER:

NAME:

MD

DO

DC

(F) IMPAIRMENT RATING (%)

(G) TO BODY OR SPECIFIC

(H) SCHEDULED MEMBER LOCATION

MEMBER:

LEFT

RIGHT

(A) LAST NAME:

(B) FIRST

(C) MI:

(D) TITLE:

(E) LICENSE NUMBER:

NAME:

MD

DO

DC

(F) IMPAIRMENT RATING (%)

(G) TO BODY OR SPECIFIC

(H) SCHEDULED MEMBER LOCATION

MEMBER:

LEFT

RIGHT

EMPLOYEE’S IME(s)

65.

(A) LAST NAME:

(B) FIRST

(C) MI:

(D) TITLE:

(E) LICENSE NUMBER:

NAME:

MD

DO

DC

(F) IMPAIRMENT RATING (%)

(G) TO BODY OR SPECIFIC

(H) SCHEDULED MEMBER LOCATION

MEMBER:

LEFT

RIGHT

EMPLOYER’S IME(s)

66.

(A) LAST NAME:

(B) FIRST

(C) MI:

(D) TITLE:

(E) LICENSE NUMBER:

NAME:

MD

DO

DC

(F) IMPAIRMENT RATING (%)

(G) TO BODY OR SPECIFIC

(H) SCHEDULED MEMBER LOCATION

MEMBER:

LEFT

RIGHT

EMPLOYEE’S VOCATIONAL EXPERT

67.

(A) LAST NAME:

(B) FIRST

(C) MI:

(D) TITLE:

(E) VOCATIONAL DISABILITY

NAME:

PHD

MA

OTHER

RATING:

EMPLOYER’S VOCATIONAL EXPERT

68.

(A) LAST NAME:

(B) FIRST

(C) MI:

(D) TITLE:

(E) VOCATIONAL DISABILITY

NAME:

PHD

MA

OTHER

RATING:

CHIROPRACTIC/PHYSICAL THERAPY

69. CHIROPRACTIC TREATMENT? YES NO

70. PHYSICIAL THERAPY? YES

NO

IF YES, NUMBER OF VISITS?

IF YES, NUMBER OF VISITS?

86. PPD%

TO BODY OR SPECIFIC MEMBER:

LEFT RIGHT

YES

NO

IF YES, NUMBER OF WEEKS?

87. PTD?

88. DEATH CLAIM? YES

NO

YES

NO

IF YES, NUMBER OF WEEKS?

89. JUDGMENT FOR EMPLOYER? YES NO

, SELECT BASIS: STATUE OF LIMITATIONS ; NOTICE ; NOT WORK RELATED ;

NO PERMANENCY ; INTOXICATION

; WILLFUL MISCONDUCT ; OTHER, SPECIFY

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91. PTD?

92. DEATH CLAIM? YES NO

YES NO

IF YES, NUMBER OF WEEKS?

93. FUTURE MEDICAL EXPENSE: CLOSED ; OPEN FOR LIFE

; OR, OPEN FOR A SPECIFIED PERIOD?

94. WAS MONEY PAID TO CLOSE FUTURE MEDICALS?

95. DATE MEDICALS WERE OR WILL BE CLOSED:

YES

NO

96. WAS CASE SETTLED PURSUANT TO TCA 50-6-206(b)?

YES NO

97. IS THIS A SECOND INJURY FUND CLAIM?

98. WAS JUDGMENT ENTERED AGAINST SECOND INJURY FUND?

YES NO

YES

NO

99. APPORTIONMENT:

(1) EMPLOYER; ____ %; #WKS; __________TOTAL AMT.

(2) SECOND INJ FUND ____ %; #WKS; _________ TOTAL AMT.

TYPE OF BENEFIT

PAID PRIOR TO TRIAL/

PAID PURSUANT TO TRIAL

PAID PURSUANT TO

TOTAL PAYMENTS

SETTLEMENT

RESULTS

SETTLEMENT TERMS

(includes medicine, PT, chiro, hospital,

MD/DO costs, tests)

107. CASE MANAGEMENT COSTS

108. DISCRETIONARY COSTS

109. AMOUNT PAID TO CLOSE FUTURE MEDICAL EXPENSE

110. LUMP SUM PAYMENT (not based on specific disability %)

111 DATE LUMP SUM PAID (not based on specific disability %): ______________________

112. TOTALS (ADD TOTALS FROM LINES 100 THRU 110)

113. AMOUNT PAID IN LUMP SUM FROM LINES 100 THRU 105; _________________________

114. DATE LUMP SUM PAID FROM LINES 100

(DO NOT ADD THIS AMOUNT TO TOTAL PAYMENTS. IT IS ALREADY INCLUDED IN THE TOTALS ABOVE.)

THRU 105 ___________________

XI. ATTORNEYS FEES

115. EMPLOYEE’S ATTORNEY FEE;

116. WAS FEE APPROVED BY COURT

AMOUNT OF AWARD ______________ % OF AWARD __________

OR TDLWD

117. EMPLOYER’S ATTORNEY FEE (SPECIFY RANGE): UNDER $1500 ; $1501-3000 ; $3000-$10,000

; OVER $10,000

XII.

CERTIFICATION AND SIGNATURES

SIGNATURE OF EMPLOYEE

DATE

SIGNATURE OF ADJUSTER/CARRIER/EMPLOYER REP

DATE SIGNED

SIGNED

SIGNATURE OF EMPLOYEE’S ATTORNEY

DATE

SIGNATURE OF EMPLOYER’S ATTORNEY

DATE SIGNED

SIGNED

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