1

TENNESSEE BUREAU OF WORKERS’ COMPENSATION

IN THE COURT OF WORKERS’ COMPENSATION CLAIMS

AT JACKSON

DERRICK WILSON, ) Docket No.: 2021-07-0482

Employee, )

v. ) State File No.: 53458-2021

RANDSTAD, INC.,

 Employer,

And

INDEMNITY INS. CO. OF N.A.,

)

)

)

)

Judge Robert Durham

Insurer. )

EXPEDITED HEARING ORDER GRANTING MEDICAL BENEFITS

This Court held an Expedited Hearing on July 28, 2022, where Mr. Wilson

requested an order requiring Randstad to offer a panel of physicians to treat his alleged 

work-related left-shoulder injury. Randstad defended on the grounds of notice and 

causation. The Court holds that Mr. Wilson is likely to prevail at trial on these issues and 

orders Randstad to provide a panel of orthopedists.

History of Claim

Before outlining the events surrounding Mr. Wilson’s alleged work-related injury, 

it is necessary to set out his medical history before working for Randstad.

In February 2009, Mr. Wilson filed a claim against his then-employer also alleging 

a left-shoulder injury. The authorized physician eventually diagnosed him with leftshoulder impingement syndrome and assigned a one-percent impairment. He also gave 

Mr. Wilson permanent physical restrictions of no more than occasional lifting overhead 

with the left shoulder and no lifting more than forty-five pounds overhead or sixty pounds 

from floor to waist. Mr. Wilson obtained a five-percent impairment from an independent 

medical examination. He settled that claim with open medical benefits in January 2010.

In 2010, Mr. Wilson stopped working due to multiple health complaints, primarily

sarcoidosis, a condition that affects his breathing, and diabetes, although he also treats for 

chronic low-back pain and severe anxiety. In 2015, he began receiving disability benefits.

FILED

Aug 09, 2022

03:50 PM(CT)

TENNESSEE COURT OF

WORKERS' COMPENSATION

CLAIMS
2

Mr. Wilson sees Dr. Stephen Collier monthly for maintenance of his health 

problems.1 According to Dr. Collier’s December 2020 note, Mr. Wilson suffered not only 

from sarcoidosis and diabetes, but also chronic low-back pain and a “history of generalized 

osteoarthritis shoulder pain.”

During the February 2021 visit, Dr. Collier noted that Mr. Wilson complained of 

“chronic low back pain secondary to degenerative disc disease.” Mr. Wilson did not 

mention shoulder pain, and he did not describe any recent acute injuries or accidents. 

However, he did say that he had “trouble climbing stairs. Has to climb a lot of ladders.

His job at the factory is very stressful and repetitive, but that is the best he can do right 

now.” The March record repeats the history given in the February note.

Regarding his employment history after receiving disability, Mr. Wilson testified 

that while he worked at a couple of factories through temporary employment agencies, he 

could not remember when he worked for them. Mr. Wilson did not elaborate on Dr. 

Collier’s notes on his employment, either on direct or cross-examination.

On March 1, 2021, Mr. Wilson applied with Randstad, a temporary employment 

agency. In the process, he signed acknowledgements that Randstad prohibited employees 

from lifting more than fifty pounds, and it required them to immediately report any work 

injury.

Randstad assigned Mr. Wilson to work at Sonoco, where he began on March 15. 

Mr. Wilson’s job required him to remove cans from an assembly line and place them in 

boxes. He did this assignment for thirty minutes and then stacked the boxes on pallets, 

which required him to occasionally lift the boxes over his head. Mr. Wilson estimated the 

boxes weighed between fifty and sixty pounds, but Brittany Bowles of Randstad testified 

the boxes weighed fewer than thirty pounds.

Mr. Wilson testified that he could not remember the exact date he injured his left 

shoulder, but it occurred when his shift was short-handed. He felt a pop in his left shoulder 

but continued to work, thinking that he might have simply strained it. He did not report it

to his supervisor at the time. Over the next few weeks, his shoulder pain worsened, and he 

told his wife that “something wasn’t right.” He estimated that the injury occurred a few 

weeks before his regularly scheduled visit with Dr. Collier, which occurred on June 8.

1 Although Mr. Wilson regularly treated with multiple physicians over the last decade, the only medical 

records in evidence that preceded his alleged injury were from his previous workers’ compensation claim 

and Dr. Collier’s records from December 2020 through March 2021. Randstad’s counsel said she had Dr. 

Collier’s records from 2018, and she asked about Mr. Wilson’s failure to respond to her efforts to obtain 

additional doctors’ notes as well as employment records. However, she did not file a motion to compel 

discovery.
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At that visit, Dr. Collier noted that Mr. Wilson was “working at a factory job” and 

had the “same chronic dull ache and stiffness as before.” However, he further observed 

that Mr. Wilson complained of “more shoulder pain” and recommended an MRI. He 

diagnosed chronic pain syndrome secondary to degenerative disease and prescribed 

medication for “left shoulder pain.” Mr. Wilson continued to work full-duty and had the 

MRI on June 30. It revealed a “full thickness, full width tear” with retraction of the 

supraspinatus tendon. 

Mr. Wilson said that the next week, before he knew the MRI results, he told his shift

leader, Adriane Ingram, that his shoulder hurt. However, he asked her not to report it 

because he wanted to give it the weekend to see if it would get better. Ms. Ingram’s 

affidavit differs somewhat. She stated that she saw Mr. Wilson doing shoulder exercises 

and asked him if he hurt it at work. She claimed he told her that he was not hurt at Sonoco 

but on a previous job. He told her about the MRI, but he repeated that his problem did not 

happen at Sonoco.

Ms. Ingram informed her supervisor of their conversation. She said that when Mr. 

Wilson found out, he confronted her, stating that “he did not want anyone to know that his 

shoulder was hurting, as it was not work-related.”

Randstad also provided the affidavit of Tony Phelps, Sonoco’s Production Shift 

Supervisor. He said that he spoke with Mr. Wilson about his left shoulder, although he 

could not remember the date. Mr. Wilson did not inform him of any specific work injury; 

instead, he said his left shoulder was “ok” and he “was fine.” He asserted that Mr. Wilson 

did not report an injury or ask for medical treatment, and he did not attend any meetings 

with Mr. Wilson or other Sonoco employees about Mr. Wilson’s work status.

Mr. Wilson’s recollection was quite different. He testified that after speaking with 

Ms. Ingram, he met with her, Mr. Phelps, and two other Sonoco employees, “Chris” and 

“Oliver.” Mr. Phelps offered to move him to another position, but Mr. Wilson declined

because he liked his current job.

Regardless, Brittany Boles, manager for Randstad, texted Mr. Wilson and asked him 

to come to Randstad’s office on July 9. At this meeting, Mr. Wilson filled out several 

forms stating that he suffered a work-related injury to his left shoulder, although he could 

not remember the exact date. Ms. Boles testified that he told her he had no idea when it 

happened. It appears that for the sake of the forms, both Ms. Boles and Mr. Wilson used 

July 8 or July 9 for the accident date. The incident form also stated that Mr. Wilson said 

the injury occurred gradually while he was lifting boxes.

After this meeting, Randstad offered Mr. Wilson a panel of physicians. He chose

Dr. Gary McBride, whom he saw on July 10. The note stated that Mr. Wilson was suffering 

from left shoulder pain for at least a month. Dr. McBride did not review the MRI, but Mr. 
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Wilson told him that it showed a tear. Dr. McBride placed Mr. Wilson on light duty and

referred him for orthopedic care.

Before Mr. Wilson could return to work on July 12, Randstad terminated his

assignment.

On July 14, he gave a recorded statement to Randstad’s carrier. In the statement, 

Mr. Wilson referred to the time when he and a co-worker were working short-handed as 

the date when he “felt like [his] arm popped.” Randstad did not authorize additional 

medical care or provide additional employment. It eventually filed a Notice of Denial.

After the denial, Dr. Collier referred Mr. Wilson to orthopedist Jason Hutchison, 

whom he saw on August 30. Dr. Hutchison diagnosed a full thickness tear of the 

infraspinatus tendon and recommended surgery.

On September 30, Dr. Hutchison responded to a letter from Mr. Wilson’s attorney 

regarding causation. He said that Mr. Wilson suffered from a significant rotator cuff tear 

that, in someone Mr. Wilson’s age, “generally occurs” with an acute injury. The letter 

asked whether Mr. Wilson’s employment could have aggravated or exacerbated a preexisting condition. Dr. Hutchison stated that Mr. Wilson did not inform him of a preexisting condition, but lifting and stacking heavy items “certainly could” cause or 

aggravate a rotator cuff tear. However, given that he might not know all of Mr. Wilson’s 

history, he reserved the right to change his opinion.

On November 8, Mr. Wilson saw orthopedist Dr. Kenneth Nord for another 

evaluation. Like Dr. Hutchison, Dr. Nord found a full thickness tear and recommended 

surgery; however, to date Mr. Wilson has not had his shoulder repaired.

On May 31, 2022, Dr. Hutchison completed a form from Randstad’s counsel. On 

the form, he acknowledged that it appeared from the records sent to him that Mr. Wilson 

had problems with his shoulder before his alleged work injury. He modified his opinion 

so that he was “unable to say with a reasonable degree of medical certainty” if the alleged 

work incident primarily caused Mr. Wilson’s rotator cuff tear.

At the hearing, Mr. Wilson attempted to clarify several points. Concerning notice, 

he explained that he had two reasons for not immediately notifying Sonoco or Randstad of 

his shoulder problems. First, after he felt the initial pop, he hoped it was just a strain that 

would improve over time. When the pain worsened over the next few weeks, he brought

it to Dr. Collier’s attention at his scheduled monthly appointment. Second, Mr. Wilson

testified that, upon seeing a co-worker lose his job after reporting an injury, he was afraid 

he would as well. 

As for causation, Mr. Wilson admitted that he did not inform any of the physicians 
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who treated him that he had a workers’ compensation claim for his left shoulder in 2009. 

However, he said the pain was nothing like what he currently suffers, and he knew that his 

shoulder was not torn in 2009 like it is now.

Finally, Mr. Wilson testified that he continues to suffer from pain and limitations in 

his left shoulder. Despite his symptoms, he is currently working for Delta Faucets and can

do his job, although Delta has prohibited him from any heavy lifting.

Findings of Fact and Conclusions of Law

Mr. Wilson must present evidence from which this Court can determine that he is 

likely to prove at trial that he provided sufficient notice of his alleged work injury and that 

it primarily arose out of and in the course and scope of his employment with Randstad. See 

McCord v. Advantage Human Resourcing, 2015 TN Wrk. Comp. App. Bd. LEXIS 6, at *9 

(Mar. 27, 2015). The Court will address each in turn.

Notice

Tennessee Code Annotated section 50-6-201(a) (2021) requires injured employees

to provide written notice within fifteen days of the injury, and if they do not, compensation 

is barred “unless reasonable excuse for failure to give the notice is made to the satisfaction 

of the tribunal to which the claim for compensation may be presented.”

Mr. Wilson did not dispute that he failed to give notice within fifteen days of hearing 

the pop in his shoulder. Although he could not testify as to the exact date, he believed the 

pop occurred a few weeks before he saw Dr. Collier on June 8.2 His MRI occurred on June

30, but he did not notify Randstad of a potential work injury until July 9. Thus, at least six 

weeks passed from the alleged injury date to Randstad receiving notice.

The question thus becomes whether Mr. Wilson had a “reasonable excuse” for 

failing to provide notice. Mr. Wilson’s situation is like that in Scruggs v. Amazon.com 

Services, LLC, 2022 TN Wrk. Comp. App. Bd. LEXIS 27, at *6-7 (June 27, 2022). In 

Scruggs, the employee injured her knee but felt that it was a temporary strain, like aches 

and pains she experienced every day, and she believed it would get better. She continued 

to work daily despite her symptoms. Three weeks later, she suffered another acute event 

that caused significant pain and swelling. It was only then that she reported the injury. The 

Appeals Board held that, under the circumstances, the employee had a reasonable excuse 

for not reporting the original injury within fifteen days. Id. at *8.

2 Mr. Scruggs’s inability to identify an exact date is not necessarily fatal to his claim. See Wolfe v. Mayes 

Mortuary, No. E2009-00406-WC-R3-WC, 2010 Tenn. LEXIS 91, at *8-9 (Tenn. Workers’ Comp. Panel 

Feb. 17, 2010) (Notice was adequate even though the employee could only identify the injury date as some 

day in “May or June of 2006.”).
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Like the employee in Scruggs, Mr. Wilson testified that he suffered from daily pain.

He initially believed his shoulder pain was no different and would eventually resolve, and

he continued to work at full duty. Mr. Wilson’s situation differs from Scruggs, in that 

several weeks passed while his symptoms grew more severe. He sought treatment from 

his family doctor, who ordered an MRI, and he did not give notice until his supervisors 

forced the issue.

However, Mr. Wilson also explained his delay even after seeing Dr. Collier. He 

testified that he watched a co-worker get fired after reporting a work injury, and he feared 

the same would happen to him. It appears his fears were justified, since Sonoco terminated 

his “assignment” the next business day, and Randstad did not offer any other employment.

Although it is close, the Court holds that Mr. Wilson’s excuses for failing to provide 

notice within fifteen days were reasonable under the circumstances.

However, even if the excuses were not reasonable, Randstad has an additional 

hurdle before it could prevail on a notice defense—it must show prejudice. Tennessee 

Code Annotated section 50-6-201(a)(3) states:

No defect or inaccuracy in the notice shall be a bar to compensation, unless 

the employer can show, to the satisfaction of the workers’ compensation 

judge before which the matter is pending, that the employer was prejudiced 

by the failure to give the proper notice, and then only to the extent of the 

prejudice.

In Scruggs, the Board held that this means the employer must prove “actual 

prejudice” caused by the employee’s late notice. Id. at *7. The employer in Scruggs

asserted that the failure to give notice was “in and of itself” a clear prejudice; however, the 

Board noted that if this were true, subsection 201(a)(3) serves no purpose. The employer 

also made a general claim that the late notice “prejudiced” its ability to investigate the 

claim without providing any facts detailing how it did so. The Board found this general 

assertion insufficient and held that the employer had not established prejudice. Id.

Here, Randstad also failed to show prejudice. It offered no evidence as to how the 

late notice might have obstructed its investigation. It obtained statements and affidavits 

from all interested parties, including Mr. Wilson. Mr. Wilson continued to work full duty 

without restrictions after his alleged injury, and Randstad introduced no evidence that his 

injury worsened while he did so. Mr. Wilson’s only unauthorized treatment before giving

notice, for which he is not seeking reimbursement, was the MRI.

Given the findings above, the Court holds that Mr. Wilson is likely to prove at trial 

that his late notice is not sufficient reason to deny his claim for benefits.
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Causation

To prevail on this issue, Mr. Wilson must show that his shoulder tear was caused by 

a “specific incident or set of incidents, arising primarily out of and in the course and scope 

of employment” with Randstad. Tenn. Code Ann. § 50-6-102(14)(A). Further, he must 

prove causation “to a reasonable degree of medical certainty,” through an expert medical 

opinion. Id.; Tenn. Code Ann. § 50-6-102(14)(D).

The facts conflict regarding the “specific incident” element, and Randstad made

several points against causation. Mr. Wilson admitted that he did not inform anyone at

Sonoco or Randstad that he suffered an injury until his supervisors approached him about 

it. According to Ms. Ingram’s and Mr. Phelps’s affidavits, he never informed them of a 

specific injury once they confronted him. Instead, he told Ms. Ingram that the injury 

occurred at a previous job. The incident report completed by Ms. Boles on July 9 states

that the injury occurred gradually due to lifting boxes. In addition, none of the medical 

records mentions a specific work incident.

Mr. Wilson’s history raises other concerns. He had a workers’ compensation claim 

in 2009 for the same shoulder that left him with permanent restrictions. Dr. Collier’s notes

before the alleged injury state that one of Mr. Wilson’s complaints was shoulder pain, 

although the records do not specify which shoulder. Finally, Dr. Collier’s February and 

March 2021 notes clearly state that Mr. Wilson was working at a factory and was suffering 

from increased pain as a result. Mr. Wilson did not clarify these statements at the hearing, 

other than to admit in his deposition that he said he worked for other temporary 

employment agencies after his 2009 workers’ compensation injuries, but he could not 

remember when.3

However, several points can also be made in Mr. Wilson’s favor. He testified that,

while he suffered from chronic pain in various body parts, including his left shoulder, 

before his injury, his left-shoulder pain did not limit his work, and he never sought specific 

treatment for it. However, he claimed his symptoms changed significantly after his injury.

The fact that he worked full duty at Randstad for several weeks before his alleged injury

tends to corroborate this statement. Mr. Wilson also explained that he did not initially 

report a work injury because of his concern, apparently legitimate, that he would lose his 

job.

The Court also finds it significant that in Mr. Wilson’s recorded statement, taken 

only a few days after he gave notice, he told the adjuster that he first felt his shoulder pop 

when he and a co-worker completed a shift short-handed. This statement is consistent with 

his hearing testimony.

3 The Court finds it curious that neither party elaborated on Mr. Wilson’s employment and the difficulties 

he had at work immediately before he began working for Randstad. 
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His medical records also contain points that corroborate causation. While he 

suffered a work injury to his left shoulder in 2009, the MRI did not reveal a tear. His 

records after the alleged injury clearly show a complete tear without atrophy, which 

suggested an acute injury to Dr. Hutchison. In addition, none of Dr. Collier’s records 

specifically mentions increased left-shoulder pain before Mr. Wilson began working at 

Randstad.

Finally, the Court finds that Mr. Wilson appeared candid and straightforward, and

Randstad did not offer sufficient evidence to cause the Court to doubt Mr. Wilson’s 

veracity. The Court cannot find, given the evidence before it, that Mr. Wilson’s testimony 

as to his alleged injury lacked credibility.

In summary, although this issue is again close, the Court holds that Mr. Wilson 

provided sufficient facts to show he is likely to prove a “specific event or series of events” 

while working at Randstad that injured his left shoulder.

Mr. Wilson must, however, still prove causation by expert medical opinion. Dr. 

McBride, the authorized physician, did not address causation. Dr. Hutchison did. After 

first stating that if Mr. Wilson’s history was correct, the tear “certainly could” have been 

caused by his employment. However, he later said that he was unable to address causation 

“to a reasonable degree of medical certainty” after being presented with information about 

Mr. Wilson’s previous workers’ compensation claim. Thus, Mr. Wilson did not show a 

likelihood of prevailing on causation through expert opinion.

However, that does not end the query. The Court must still consider Mr. Wilson’s

entitlement to a panel of orthopedists as recommended by Dr. McBride. Tennessee Code 

Annotated section 50-6-204(a)(3)(A)(i). The Appeals Board has long held that a lack of 

medical evidence regarding causation does not necessarily eliminate the employer’s 

obligation to provide a physician panel. Lewis v. Molly Maid, 2016 TN Wrk. Comp. App. 

Bd. LEXIS 19, at *8-9 (Apr. 20, 2016); Hawes v. McLane Co., Inc., 2021 TN Wrk Comp. 

App. Bd. LEXIS 30, at *10 (Aug. 25, 2021). 

In Hawes, the only medical evidence was from a non-doctor clinician, who gave an 

opinion that the employee’s condition was not work-related. The Appeals Board 

distinguished the case from Berdnik v. Fairfield Glade Com’ty Club, 2017 TN Wrk. Comp. 

App. Bd. LEXIS 32, at *10-11 (May 18, 2017), where the only evidence from a doctor was

that the employee’s condition was not causally related to employment, leading the Appeals 

Board to deny the employee a panel. Id. Thus, the Appeals Board in Hawes held that a 

non-medical opinion against causation was not enough reason to deny the provision of a 

panel. Id.

As with Hawes, no doctor opinion exists in this case as to whether Mr. Wilson’s 
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rotator cuff tear is or is not causally related to his employment with Randstad. Thus, the 

Court holds that Randstad must provide Mr. Wilson with a panel of orthopedists from 

which he may choose an authorized physician under Tennessee Code Annotated section 

50-6-204(a)(3)(A)(i). 

IT IS, THEREFORE, ORDERED THAT: 

1. Randstad shall provide Mr. Wilson with a panel of orthopedists, from which he 

may select a physician to treat any injury he sustained to his left shoulder while 

working for Randstad. 

2. This case is set for a Status Hearing on September 26, 2022, at 9:00 a.m. 

Central Time. The parties must call 615-253-0010. Failure to appear might 

result in a determination of the issues without the party’s participation. 

3. Unless interlocutory appeal of the Expedited Hearing Order is filed, compliance 

with this Order must occur no later than seven business days from the date of 

entry of this Order as required by Tennessee Code Annotated section 50-6-

239(d)(3). The Insurer or Self-Insured Employer must submit confirmation of 

compliance with this Order to the Bureau by email to 

WCCompliance.Program@tn.gov no later than the seventh business day after 

entry of this Order. Failure to submit the necessary confirmation within the 

period of compliance might result in a penalty assessment for non-compliance. 

For questions regarding compliance, please contact the Workers’ Compensation 

Compliance Unit via email at WCCompliance.Program@tn.gov.

ENTERED on August 9, 2022. 

_____________________________________ 

 ROBERT DURHAM, JUDGE 

Court of Workers’ Compensation Claims 

APPENDIX 

Technical Record: 

1. Petition for Benefit Determination 

2. Dispute Certification Notice 

3. Request for Expedited Hearing 

4. Notice of Hearing 

5. Mr. Wilson’s Pre-Hearing Brief 

6. Randstad’s Witness and Exhibit List 

7. Randstad’s Pre-Hearing Brief 
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Exhibits: 

1. Mr. Wilson’s affidavit 

2. The Jackson Clinic’s medical record 

3. West Tennessee Bone and Joint’s medical record 

4. Sports Orthopedic and Spine medical record 

5. Randstad’s collective exhibit of medical records 

6. Affidavits of Tangie Barlow, Adriane Ingram, and Tony Phelps 

7. First Report of Injury 

8. Wage Statement 

9. Notice of Denial 

10.C-42 

11.Recorded Statement 

12.Documents from 2010 worker’s compensation settlement 

13.Mr. Wilson’s deposition 

CERTIFICATE OF SERVICE

I certify that a copy of the Order was sent as indicated on August 9, 2022. 

Name Certified 

Mail

Via

Fax

Via 

Email

Service sent to:

Jeffrey Boyd X jboyd@borenandboyd.com

Laurenn Disspayne X ldisspayne@manierherod.com

_____________________________________ 

 PENNY SHRUM, Court Clerk 

WC.CourtClerk@tn.gov
For self-represented litigants: Help from an Ombudsman is available at 800-332-2667.

Expedited Hearing Order Right to Appeal:

If you disagree with this Expedited Hearing Order, you may appeal to the Workers’ 

Compensation Appeals Board. To appeal an expedited hearing order, you must:

1. Complete the enclosed form entitled: “Notice of Appeal,” and file the form with the 

Clerk of the Court of Workers’ Compensation Claims within seven business days of the 

date the expedited hearing order was filed. When filing the Notice of Appeal, you must 

serve a copy upon all parties. 

2. You must pay, via check, money order, or credit card, a $75.00 filing fee within ten 

calendar days after filing of the Notice of Appeal. Payments can be made in-person at 

any Bureau office or by U.S. mail, hand-delivery, or other delivery service. In the 

alternative, you may file an Affidavit of Indigency (form available on the Bureau’s 

website or any Bureau office) seeking a waiver of the fee. You must file the fullycompleted Affidavit of Indigency within ten calendar days of filing the Notice of 

Appeal. Failure to timely pay the filing fee or file the Affidavit of Indigency will 

result in dismissal of the appeal.

3. You bear the responsibility of ensuring a complete record on appeal. You may request 

from the court clerk the audio recording of the hearing for a $25.00 fee. If a transcript of 

the proceedings is to be filed, a licensed court reporter must prepare the transcript and file 

it with the court clerk within ten business days of the filing the Notice of 

Appeal. Alternatively, you may file a statement of the evidence prepared jointly by both 

parties within ten business days of the filing of the Notice of Appeal. The statement of 

the evidence must convey a complete and accurate account of the hearing. The Workers’ 

Compensation Judge must approve the statement before the record is submitted to the 

Appeals Board. If the Appeals Board is called upon to review testimony or other proof 

concerning factual matters, the absence of a transcript or statement of the evidence can be 

a significant obstacle to meaningful appellate review.

4. If you wish to file a position statement, you must file it with the court clerk within ten

business days after the deadline to file a transcript or statement of the evidence. The 

party opposing the appeal may file a response with the court clerk within ten business 

days after you file your position statement. All position statements should include: (1) a 

statement summarizing the facts of the case from the evidence admitted during the 

expedited hearing; (2) a statement summarizing the disposition of the case as a result of 

the expedited hearing; (3) a statement of the issue(s) presented for review; and (4) an 

argument, citing appropriate statutes, case law, or other authority.
LB-1099 rev. 01/20 Page 1 of 2 RDA 11082 

NOTICE OF APPEAL 

Tennessee Bureau of Workers’ Compensation

www.tn.gov/workforce/injuries-at-work/ 

wc.courtclerk@tn.gov | 1-800-332-2667 

Docket No.: ________________________

State File No.: ______________________ 

Date of Injury: _____________________ 

___________________________________________________________________________ 

Employee

v.

___________________________________________________________________________ 

Employer

Notice is given that ____________________________________________________________________ 

[List name(s) of all appealing party(ies). Use separate sheet if necessary.]

appeals the following order(s) of the Tennessee Court of Workers’ Compensation Claims to the 

Workers’ Compensation Appeals Board (check one or more applicable boxes and include the date filestamped on the first page of the order(s) being appealed):

□ Expedited Hearing Order filed on _______________ □ Motion Order filed on ___________________

□ Compensation Order filed on__________________ □ Other Order filed on_____________________

issued by Judge _________________________________________________________________________. 

Statement of the Issues on Appeal 

Provide a short and plain statement of the issues on appeal or basis for relief on appeal: 

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Parties

Appellant(s) (Requesting Party): _________________________________________ ☐Employer ☐Employee 

Address: ________________________________________________________ Phone: ___________________ 

Email: __________________________________________________________ 

Attorney’s Name: ______________________________________________ BPR#: _______________________ 

Attorney’s Email: ______________________________________________ Phone: _______________________ 

Attorney’s Address: _________________________________________________________________________ 

* Attach an additional sheet for each additional Appellant *
LB-1099 rev. 01/20 Page 2 of 2 RDA 11082 

Employee Name: _______________________________________ Docket No.: _____________________ Date of Inj.: _______________ 

Appellee(s) (Opposing Party): ___________________________________________ ☐Employer ☐Employee 

Appellee’s Address: ______________________________________________ Phone: ____________________ 

Email: _________________________________________________________ 

Attorney’s Name: _____________________________________________ BPR#: ________________________ 

Attorney’s Email: _____________________________________________ Phone: _______________________ 

Attorney’s Address: _________________________________________________________________________ 

* Attach an additional sheet for each additional Appellee *

CERTIFICATE OF SERVICE 

I, _____________________________________________________________, certify that I have forwarded a 

true and exact copy of this Notice of Appeal by First Class mail, postage prepaid, or in any manner as described 

in Tennessee Compilation Rules & Regulations, Chapter 0800-02-21, to all parties and/or their attorneys in this 

case on this the __________ day of ___________________________________, 20 ____. 

 ______________________________________________ 

[Signature of appellant or attorney for appellant]