A Request for Assistance is a formal way to ask the Tennessee Department of Labor to intervene in your claim to resolve a conflict between you and your employer/work comp. insurance company.
As an example, if an injured employee’s medical treatment is being denied, or they are not receiving their temporary disability payments the employee can file a Request for Assistance. This is an efficient way to address a conflict under Tennessee workers’ compensation law, through the Tennessee Department of Labor, prior to taking action in court. If you are have questions concerning your Tennessee work comp. claim, feel free to contact our office at Attorney Cody Allison & Associates / The Work Comp. Team (615) 234-6000.
Below is a copy of the Request for Assistance form from the Tennessee Department of Labor. You can access the form through the Tennessee Department of Labor’s website. If you have any questions about the form you should contact the Tennessee Department of Labor and/or a Tennessee attorney who handles workers’ compensation claims.
________________________________________________________________________
FORM C40A LB-0381 (REV. 04/09) Pg 1 of 2 RDA 10183
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers’ Compensation
2222 Rosa L. Parks Blvd.
Nashville, Tennessee 37228
Toll Free: 1-800-332-2667
FAX: 615-253-1223 or 615-253-2479
REQUEST FOR ASSISTANCE
Failure To Complete All Items On This Form Will Cause Delay In Processing And May Result In The Form Being Returned To The Requesting Party. For assistance in completing this form call 1-800-332-2667.
It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers’ compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits.
A) DATE OF INJURY:
B) ASSISTANCE IS REQUESTED FOR: (Check all that apply)
Temporary Disability Benefits: Medical Care Benefits:
Penalty for late payment or non-payment of benefits: Discovery:
C)INJURED EMPLOYEE’S NAME:
SSN: Date of Birth:
Street Address:
City: State: Zip:
County: Phone:
Email Address:
Is Employee Represented By An Attorney?
Attorney’s Name:
Mailing Address:
Telephone: Fax:
Email Address:
D) EMPLOYER’S NAME:
Street Address:
City: State: Zip:
County: Telephone:
Email Address:
Is Employer Represented By An Attorney?
Attorney’s Name:
Mailing Address:
Telephone: Fax:
Email Address:
Do Five Or More Employees Work For Employer?
E) WORKERS’ COMPENSATION INSURANCE COMPANY:
Company Name:
Street Address:
City: State: Zip:
Adjuster’s Name:
Telephone: Fax:
Email Address:
F) BRIEF DESCRIPTION OF INJURY:
Nature of Injury (carpal tunnel, broken arm, etc.)
How injury occurred (fell, lifting, driving, etc.)
_____________________________________________________________________
When did Employee report injury to employer?
To Whom? Person’s Title:
How long has Employee worked for employer?
County of Injury:
G) MEDICAL TREATMENT:
Was Employee given a choice of three (3) or more treating doctors?
If a panel was provided, which doctor was selected?
(Please attach all relevant records resulting from medical treatment for this injury.
Failure to do so may result in resolution of your request being delayed.)
DESCRIBE COMPLAINT OR REASON FOR REQUEST:
________________________________________________________________________
For faster service, you may send your completed form directly to the local office that will handle your request. You can find a map of the offices along with addresses and phone numbers by checking our website at http://www.state.tn.us/labor-wfd/wc_map.pdf
I hereby request the Department of Labor and Workforce Development to assist in any disputed workers’ compensation issues related to the above-detailed injury. I also authorize the Department of Labor and Workforce Development to contact any person who has information regarding that injury. If the undersigned is the Injured Employee or the Injured Employee’s legal representative, authorization is also given to the Department of Labor and Workforce Development to use the Injured Employee’s social security number in any manner necessary to provide the requested assistance.
DATE:
SIGNATURE OF REQUESTING PARTY
PRINTED NAME OF REQUESTING PARTY
REQUEST FOR ASSISTANCE form must be signed by Requesting party or authorized representative
RFA NUMBER
STATE FILE NUMBER FORM C40A LB-0381 (REV. 04/09) Pg 2 of 2 RDA 10183
Nashville, Tennessee workers’ compensation / Middle Tennessee workers’ compensation / Davidson County workers’ compensation