Loading
Get Tn Lb-0930 2018-2025
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the TN LB-0930 online
Filling out the TN LB-0930 form online can be a straightforward process when guided properly. This document is essential for requesting a medical impairment rating through the Tennessee Bureau of Workers’ Compensation.
Follow the steps to successfully complete the form.
- Click ‘Get Form’ button to access the TN LB-0930 document and open it for editing. This action allows you to begin filling out the form needed for your request.
- Select the requesting party by checking the appropriate box, indicating whether you are the employee, employee attorney, employer/carrier, or employer/carrier attorney.
- Enter your state file number, date of injury, and date of maximum medical improvement (MMI) in the designated fields.
- List all affected body parts or organ systems for which you are disputing the medical impairment rating. Specify the body parts and any relevant details such as side (left or right) and joint information.
- Fill in the employee’s personal information, including name, social security number, date of birth, phone number, email address, and home address.
- Provide details of the employee's attorney, if applicable, by entering their name, email, practice name, and business address.
- Indicate whether an interpreter is needed for the evaluation, and if so, provide the primary language spoken.
- Answer questions regarding the involvement of a Bureau of Workers’ Compensation specialist, mediation requests, and the Second Injury Fund, as applicable.
- Fill in the employer’s information, including name, address, and attorney details.
- List all physicians who have issued an impairment rating, including their name, practice name, address, body part evaluated, work-related diagnosis, and impairment rating.
- Provide the names of all treating physicians with their details as necessary.
- Complete the certificate of mailing section to confirm copies of the application have been sent to relevant parties.
- Finally, ensure all information is accurate, then save changes, download, print, or share the completed form as required.
Begin filling out the TN LB-0930 online today to streamline your request process.
Applying for a workers' comp exemption in Tennessee involves submitting a specific form to the relevant state department. You must provide detailed information about your business structure and any factors that justify the exemption. Using tools from uslegalforms can streamline your application process in compliance with TN LB-0930. Ensure that your application is complete to avoid delays in receiving your exemption status.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.