Court Opinion

ID: 4707977
Source: CourtListenerOpinion
Date Created: 2021-07-30 15:00:07.034591+00
Date Added: 2024-06-11T08:06:47.371569
License: Public Domain

FILED
                                                                                            Jul 22, 2021
                                                                                           07:15 AM(CT)
                                                                                        TENNESSEE COURT OF
                                                                                       WORKERS' COMPENSATION
                                                                                              CLAIMS

             TENNESSEE BUREAU OF WORKERS’ COMPENSATION
            IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
                            AT COOKEVILLE

KENNETH RAY, JR.,                                  ) Docket No 2020-04-0228
           Employee,                               )
v.                                                 )
ROLLINS, INC.,                                     ) State File No. 90714-2018
           Employer,                               )
And                                                )
NEW HAMPSHIRE INS. CO.,                            ) Judge Robert Durham
           Carrier,                                )
And                                                )
ABIGAIL HUDGENS, Director, and                     )
The    Subsequent    Injury  and                   )
Vocational                                         )
Recovery Fund.

          COMPENSATION HEARING ORDER GRANTING BENEFITS

       The Court held a Compensation Hearing on June 21, 2021, to determine Mr. Ray’s
vocational disability following his work-related injury, and, if he is totally disabled,
whether the Subsequent Injury and Vocational Recovery Fund (SIF) retains any liability.
The Court holds that Mr. Ray is permanently and totally disabled, and Rollins is solely
responsible for paying disability benefits.

                                         History of Claim

       The parties agreed that Mr. Ray, as an employee of Rollins, sustained a
compensable L4-5 disc herniation while treating a house for termites on November 26,
2018. 1 He received authorized treatment from neurosurgeon Dr. Jacob Schwarz, who

1
 The parties also agreed to the following: Mr. Ray’s anatomic impairment rating is twelve percent to the
body as a whole; his compensation rate is $602.89; he reached maximum medical improvement on
October 31, 2019; Rollins paid $58,717.54 as an advance against permanent disability benefits; and, Mr.
Ray was unable to return to his previous employment with Rollins, which entitles him to benefits beyond
his initial compensation period.
                                                   1
ultimately performed an L4-5 discectomy and fusion.

        Dr. Schwarz testified that after Mr. Ray reached maximum medical improvement,
he still suffered from substantial limitations due to his work injury. Thus, he assigned
permanent restrictions based on a functional capacity evaluation.

        The functional capacity evaluation stated that Mr. Ray could work at the “Light to
Light-Medium” physical demand level and assigned the following physical limitations:
(1) maximum occasional lifting/carrying of twenty-five to thirty-five pounds; (2)
maximum occasional lifting from floor of thirty pounds; (3) maximum occasional pull
activities of sixty-five pounds; (4) occasional bending to approximately fifty-five degrees
of lumbar flexion; (5) no stooping more than thirty seconds at a time or for more than ten
percent of the work day; (6) no crawling on a repetitive/frequent basis or for more than
ten percent of the workday; and (7) alternate “sit/static stand/walk positions” every thirty
minutes if needed.

        Dr. Schwarz also testified about Mr. Ray’s earlier discectomy at L4-5 to repair a
herniation that resulted from a previous work injury at Rollins. He understood that Mr.
Ray fully recovered from that surgery without symptoms or restrictions and had returned
to full duty with Rollins. Dr. Schwarz stated that Mr. Ray’s need for the more recent
fusion was due to his 2018 injury and not to any instability created by the previous
surgery. Further, the earlier injury was not a factor when he assigned Mr. Ray’s anatomic
impairment and physical restrictions.

        Finally, Dr. Schwarz agreed that, based on the job description, Mr. Ray could not
return to his previous employment with Rollins due to his physical restrictions. 2

                                           Lay Testimony

       Mr. Ray also testified as to his education and job history. He is currently forty-
one years old. He quit school after completing the tenth grade but obtained his GED
shortly afterward. He has no other formal education other than some training in pest
control required by his job at Rollins.

       Mr. Ray’s first jobs after leaving high school consisted of factory work and
working as a dry-wall installer and a plumber’s helper. He then spent two years as a
press operator before working as a carpenter and interior finisher for a builder for six
years. He testified that all these jobs involved moderate to heavy manual labor and
required a great deal of physical activity as well as extensive standing and walking.
2
  Dr. Schwarz provided this opinion in response to a question regarding Tennessee Code Annotated
section 50-6-242(a)(2)(B), which requires the treating doctor to certify on a form that the employee is
unable to return to pre-injury employment. Later, he signed the form, but the form did not identify Mr.
Ray. Given the circumstances, the Court overruled Rollins’s objection to the form’s admissibility.
                                                  2
        In 2012, Mr. Ray began working for Rollins. As a termite technician, he spent
much of his workday crawling through narrow spaces and working in cramped
conditions. He had to haul trash from these crawl spaces to his truck and used a heavy
drill to drill holes into concrete and wood to inject pesticides into infected spaces. He
also worked for hours stooped over to spray chemicals into cracks and crevices.

       Mr. Ray testified that he could no longer do any of his former jobs, including his
job with Rollins, due to the physical limitations from his back injury. He said he lacks
any computer skills and does not own a computer. He has not applied for a job since
reaching maximum medical improvement because he does not believe there are any jobs
that he can perform on a consistent basis given his limitations.

       Although he suffered previous work injuries to his shoulder and low back while at
Rollins, he made full recoveries from them. He had no symptoms or physical restrictions
from either injury before the 2018 incident.

       Regarding his current condition, Mr. Ray testified the fusion provided some relief,
but he still suffers from significant low-back and right-knee pain. 3 He is currently under
a pain management regimen that is treating him without narcotics. He can do some light
housekeeping, such as vacuuming, dishwashing and laundry, so long as he takes frequent
breaks during each task. He must lie down several times a day to “stretch out” his back
and right leg. He cannot mow his lawn or go boating because of the vibrations. He can
only sit for an hour or so while driving before he needs a substantial break to walk and
stretch his back. He cannot sit in bleachers to watch his daughter cheerlead or play ball
with his young son. Mr. Ray further testified that his pain only allows him to sleep three
to four hours a night.

       Mr. Ray’s wife of twenty-years, Christina Ray, confirmed her husband’s
testimony about his limitations. She also testified that his physical condition has caused
significant stress in their marriage.

                                    Expert Vocational Testimony

       Mr. Ray and Rollins both brought experts to testify as to the extent of his
vocational disability. Mr. Ray proffered Michael Galloway, a certified rehabilitation
counselor who has operated a vocational consulting service since 1998. Rollins called
Robert Kennon Ph.D., a licensed psychologist and board-certified forensic examiner, who
has performed vocational evaluations since 1997.

3
 Mr. Ray has complained of debilitating right-knee pain since the injury, but testing has not revealed any
abnormalities, and Dr. Schwarz declined to comment on the source of the knee pain.
                                                    3
        Mr. Galloway’s and Dr. Kennon’s findings were quite similar in many ways. Both
found Mr. Ray to be very candid and credible with legitimate expressions of pain. They
also obtained similar results when testing Mr. Ray’s intellectual capacity, finding that he
was at “low-average to average” levels in reading and math skills, which were consistent
with his age, education, and training. Dr. Kennon additionally gave Mr. Ray an
intelligence test, which also placed him in the “low-average” range. They agreed that
Mr. Ray’s work experience was mostly in jobs in the medium to heavy labor categories.
Where they differed was to what extent Mr. Ray’s physical limitations, as described in
the functional capacity evaluation, prevented him from finding work in the general labor
market.

       Mr. Galloway believed Mr. Ray to be totally vocationally disabled. First, he did
not think Mr. Ray could return to any job that required significant physical activity.
Thus, he did not have any transferable job skills based on his prior employment. Second,
Mr. Galloway felt that Mr. Ray’s inexperience, intellectual capacity, and complete lack of
basic computer skills made retraining for jobs within his physical capabilities unlikely.
Finally, he observed that the restrictions on stooping and requiring Mr. Galloway to shift
from sitting/walking/standing every half hour are restrictions that few employers can
effectively accommodate. This is especially true considering Mr. Ray’s testimony that he
must lie down four or five times a day to “stretch out” his back and leg.

       Dr. Kennon agreed with Mr. Galloway that Mr. Ray was substantially disabled,
but he did not believe the disability was total. He placed Mr. Ray’s vocational disability
within a range based on the availability of light- and medium-level jobs. In the light
category, he determined that Mr. Ray has lost 87.17% of “highly transferable” job titles
and 77.40% of “moderately transferable” jobs. In the medium category, he calculated
Mr. Ray’s job loss as 68.1% of “highly transferable” jobs and 55.8% of “moderately
transferable” jobs.

       However, Dr. Kennon conceded that Mr. Ray’s restrictions caused some difficulty
in determining impairment. First, many of his restrictions fit into a “light-medium”
category rather than “medium.” Therefore, Mr. Ray’s actual disability in the medium
category was likely understated. Dr. Kennon had similar difficulty with the restrictions
against stooping and crawling more than ten percent of the day, since they were more
than “never” but less than “occasional,” which is defined as one-third of the workday.

       In addition, Dr. Kennon acknowledged the challenge in calculating job loss based
on the restriction that Mr. Ray should change from sitting/standing/walking every half-
hour. Since Dr. Schwarz did not elaborate how long Mr. Ray could remain in each
position, Dr. Kennon categorized Mr. Ray as being able to sit/stand/walk on a “frequent”
basis, which is defined as two-thirds of the workday. Dr. Kennon agreed that if this
assumption were incorrect, Mr. Ray’s vocational impairment would be greater.

                                            4
        Dr. Kennon conceded that Mr. Ray would likely need a “sympathetic employer”
who was willing to work with his physical restrictions before he could make a successful
return to the labor market. Nevertheless, he believed that Mr. Ray was not totally
disabled and had the capability to retrain for employment that would accommodate his
restrictions through a vocational rehabilitation program or community college.

                           Findings of Fact and Conclusions of Law

       Mr. Ray has the burden of proving the essential elements of his workers’
compensation claim by a preponderance of the evidence. Scott v. Integrity Staffing
Solutions, 2015 TN Wrk. Comp. App. Bd. LEXIS 24, at *6 (Aug. 18, 2015). However,
in this case, the parties have stipulated to all issues except the extent of Mr. Ray’s
permanent disability, and if he is permanently and totally disabled, whether the SIF
retains any liability.

                                    Extent of Disability

        Tennessee Code Annotated section 50-6-207(4)(B) provides that employees who
suffer an injury that “totally incapacitates [them] from working at an occupation that
brings [them] an income” shall be considered totally disabled. In determining whether an
employee is totally disabled, the Court must focus on the employee’s “ability to return to
gainful employment.” Cleek v. Wal-Mart Stores, Inc., 19 S.W.3d 770, 774 (Tenn. 2000).
In Hubble v. Dyer Nursing Home, 188 S.W.3d 525, 535 (Tenn. 2006), the Supreme Court
listed several factors relevant to the question of total disability: “the employee’s skills,
training, education, age, job opportunities in the immediate and surrounding
communities, and the availability of work for an individual with that particular
disability.”

        Mr. Ray and Rollins provided vocational experts to testify as to the extent of Mr.
Ray’s vocational disability. When weighing expert opinions, the Court may consider,
among other things, “the qualifications of the experts, the circumstances of their
examination, the information available to them, and the evaluation of the importance of
that information by other experts.” Bass v. The Home Depot U.S.A, Inc., 2017 TN Wrk.
Comp. App. Bd. LEXIS 36, at *9 (May 26, 2017).

        Here, the Court finds that Mr. Galloway and Dr. Kennon are well-qualified to
provide an expert opinion, and one does not hold a clear advantage over the other. The
Court also notes that their testimony was similar in many ways. Both experts found that,
given his education, past job experience, and physical limitations, Mr. Ray had little in
the way of transferable job skills. Their intellectual testing revealed Mr. Ray was in the
“low-average to average” range in reading and math, which was consistent with his age,
education, and job history. However, Dr. Kennon was more confident in Mr. Ray’s
intellectual capacity, given that he felt Mr. Ray was capable of retraining and would

                                             5
benefit from a vocational rehabilitation program or even community college.

        The most significant difference in the expert opinions is their interpretation of the
functional capacity evaluation restrictions adopted by Dr. Schwarz, particularly as to
changing from walking/standing/sitting every half-hour. Mr. Galloway believed this
restriction effectively precluded Mr. Ray from working even sedentary jobs and thus
found Mr. Ray to be 100 percent vocationally disabled from the general labor market.

        On the other hand, Dr. Kennon found the functional capacity evaluation
restrictions to be ambiguous, which made it difficult to classify Mr. Ray’s vocational
impairment. As a result, Dr. Kennon provided a range of impairment for both “light” and
“medium” categories that resulted in a 77.4% to 87.1% disability in “light” jobs and a
55.8% to 68.1% disability in medium jobs. However, he admitted that the disability
range was probably higher given Mr. Ray’s actual restrictions. Dr. Kennon conceded that
any employment Mr. Ray finds must be with an employer “sympathetic” to his
limitations and willing to provide accommodations.

       In addition to expert opinion, the “employee’s own assessment of his or her
overall physical condition, including the ability or inability to return to gainful
employment, is competent testimony that must be considered” when determining
vocational disability. Hubble, 188 S.W.3d at 535-36. Dr. Schwarz, Mr. Galloway, and
Dr. Kennon all considered Mr. Ray to be truthful with no evidence of malingering. All
believed him to be in genuine pain. Upon observing Mr. Ray at the hearing, the Court
agrees with this undisputed testimony. Mr. Ray frequently alternated between sitting and
standing during the hearing, and the Court observed that when he did sit, he braced
himself with his elbows on his chair arms to take as much weight off his back as possible.

        Mr. Ray testified that he is in constant pain in his back to his right knee with
activity aggravating his symptoms to the point of debilitation. He sleeps three to four
hours a night due to his pain. He can only engage in limited activity that requires
frequent breaks that are at least several minutes in length.

        He testified that even on “good days,” he must lie down several times a day to get
some relief. Mr. Galloway and Dr. Kennon both said that they did not consider this
limitation because it was not part of the functional capacity evaluation, but they agreed
that this would limit the jobs available to him even more.

       Mr. Ray admitted that he has not applied for work since his injury because he does
not believe there are any jobs that he can do in his current condition. Given the evidence,
the Court agrees with this assessment, as Mr. Ray’s testimony supports Mr. Galloway’s
interpretation of the functional capacity evaluation. Thus, the Court holds that Mr. Ray is
permanently and totally disabled from gainful employment under Tennessee Code
Annotated section 50-6-207(4)(B).

                                             6
                                       SIF Liability

      The Court now considers whether the SIF retains any liability for Mr. Ray’s
permanent total disability benefits. Tennessee Code Annotated § 50-6-208(a)(1)
provides:

       If an employee has previously sustained a permanent physical disability
       from any cause or origin and becomes permanently and totally disabled
       through a subsequent injury, the employee shall be entitled to compensation
       from the employee’s employer only for the disability that would have
       resulted from the subsequent injury …. The remainder of the compensation
       that would be due for the permanent total disability [shall be paid] out of
       the …. subsequent injury and vocational recovery fund.

       Subsection (a)(2) goes on to say that for an employee to receive SIF funds, the
employer must show that it had actual knowledge of the employee’s pre-existing
disability at the time he was hired or retained in employment. It is undisputed that Mr.
Ray sustained a previous work-related shoulder injury and a previous work-related disc
herniation at L4-5 while employed with Rollins. Thus, Rollins was aware of those
injuries when it hired Mr. Ray.

        However, no evidence showed that Mr. Ray was in any way disabled by those
injuries. He testified that he made a full recovery with no limitations on his activities
from both injuries. Rollins did not provide any evidence to the contrary. Dr. Schwarz
testified unequivocally that, even though the herniation he treated was at the same level
as the previous herniation, his impairment rating and permanent restrictions were due
solely to the 2018 herniation. Rollins did not offer any evidence to counter this opinion.

       The Court finds no evidence that Mr. Ray suffered a “permanent physical
disability” due to his previous work-related injuries. Thus, the SIF retains no liability for
Mr. Ray’s permanent and total disability benefits.

                                Commutation to Lump Sum

        Tennessee Code Annotated section 50-6-207(4)(A)(ii)(a) provides that permanent
total disability benefits “may be commuted to a lump sum to pay only the employee’s
attorney’s fees and litigation expenses and to pay pre-injury obligations in arrears.” Even
then, the “commuted portion of an award shall not exceed the value of one hundred (100)
weeks of the employee’s benefits.” Id. at (ii)(b).

      Here, the Court finds it appropriate to commute 100 weeks of the award to pay
Mr. Ray’s attorney’s fees and litigation expenses. Tennessee Code Annotated section 50-

                                             7
6-229(a) allows commutation of attorney fees if “approved and ordered by the trial
judge.” Thus, the Court commutes 100 weeks of the award and orders Rollins to pay it in
a lump sum of $60,289.00 (100 weeks times $602.89).

       The remaining amount of the award shall be paid periodically. To determine the
amount of weekly benefits Mr. Ray shall receive from Rollins, the Court must first
deduct the lump sum payment from the total amount Mr. Ray would receive if benefits
are paid until he becomes eligible for full social security retirement benefits. After
dividing this amount by the number of weeks Mr. Ray is entitled to permanent total
disability benefits, the Court holds that Rollins shall pay Mr. Ray permanent total
disability benefits in the amount of $562.19 per week as long as he is eligible.

                                      Attorney’s fees

       As to the amount of Ms. Draughon’s attorney’s fee, Tennessee Code Annotated
section 50-6-207(4)(a)(iii) provides that fees in permanent total disability cases “shall be
calculated upon the first four hundred and fifty (450) weeks of disability only.” Further,
under section 226(a)(1), any attorney fee shall not exceed twenty percent of the award.

       Ms. Draughon’s application for attorney’s fees in the amount of $54,260.10, or
20% of the first 450 weeks of permanent total disability benefits, is uncontested and
supported by her affidavit as required by Tennessee Code Annotated section 50-6-
226(a)(2)(C). The Court find this award is justified according to the criteria in Tennessee
Supreme Court Rule 8, RPC 1.5. Thus, the Court awards Ms. Draughon attorney’s fees
in the amount of $54,260.10 to be paid from the commutation of Mr. Ray’s award. The
remaining amount may be used to pay Mr. Ray’s litigation expenses.

                                       Discretionary Costs

       As for discretionary costs, Tennessee Code Annotated section 50-6-239(c)(8)
gives the Court discretion to award costs “including reasonable fees for depositions of
medical experts” against the employer “upon adjudication of the claim as compensable.”
Rollins argues that discretionary costs should not be awarded in this case because it
stipulated to compensability, but it did not cite any authority for this position. The Court
interprets the statute to mean the claim must be compensable, not that compensability
must be disputed, before it may award costs. Thus, the Court holds that awarding
discretionary costs to Mr. Ray is appropriate in this case.

       In addition to section 50-6-239(c)(8), Tennessee Rules of Civil Procedure Rule
54.04 further defines allowable “discretionary costs” as follows:

       [R]easonable and necessary court reporter expenses for depositions or
       trials, reasonable and necessary expert witness fees for depositions (or

                                             8
       stipulated reports) and for trials, reasonable and necessary interpreter fees
       not paid pursuant to Tennessee Supreme Court Rule 42, and guardian ad
       litem fees; travel expenses are not allowable discretionary costs.

       Mr. Ray asked for reimbursement of several different expenses:

   1) Mr. Galloway’s vocational evaluation and deposition and trial preparation;
   2) Mr. Galloway’s fees for testifying in his discovery deposition and at trial; and,
   3) Court reporter fees for witness depositions and the trial.

The Court will address each in turn.

       In Garassino v. W. Express, Inc., No. M2016-02431-SC-R3-WC, 2018 Tenn.
LEXIS 60, at *7-8 (Tenn. Workers’ Comp. Panel Feb. 8, 2018), the Panel held that the
costs “for expert witness fees for preparing for depositions or trial, no matter how
reasonable these fees are,” are not recoverable discretionary costs in Rule 54.04(2) of the
Tennessee Rules of Civil Procedure. Thus, the Court denies Mr. Ray’s request for
reimbursement of Mr. Galloway’s vocational evaluation as well as any costs associated
with his preparation for deposition or trial.

        As for Mr. Galloway’s travel expenses, the plain language of Rule 54.04 states
that travel expenses are not allowable discretionary costs. Thus, Mr. Ray is not entitled
to reimbursement for Mr. Galloway’s travel expenses.

        Regarding Mr. Galloway’s fees for deposition and trial testimony, the Court relied
upon his testimony to make its ruling. The Court further finds that Mr. Galloway’s
charges for his testimony comports with Tennessee Compilation Rules and Regulations
0800-02-21-.18(4) (August, 2019). regarding charges for medical depositions. Thus, the
Court holds that $1,950.00 is a reasonable cost for Mr. Galloway’s testimony, and Rollins
shall reimburse Mr. Ray in that amount.

      Finally, Rollins did not object to the amount of Mr. Ray’s court reporter expenses.
Thus, Rollins shall also pay Mr. Ray $630.10 as reimbursement for court reporter
expenses.

       Given the regulations and statutes cited above, and based on the circumstances of
this case, the Court holds that reimbursement of Mr. Ray’s costs in the amount of
$2,580.10 is reasonable, and Rollins shall pay this amount to Mr. Ray. The Court further
awards Ms. Draughon attorney’s fees of $54,260.10, or twenty percent of Mr. Ray’s
award for permanent total disability benefits.

IT IS, THEREFORE, ORDERED THAT:

                                             9
   1. Mr. Ray is entitled to an award of permanent and total disability benefits. Rollins
      shall pay accrued benefits in a lump sum from October 31, 2019, the date of
      maximum medical improvement, through the date this order becomes final, less a
      credit of $58,717.54 already paid as an advance against permanent disability
      benefits. Rollins shall also pay a lump-sum payment of $60,289.00, from which
      Ms. Draughon shall receive $54,260.10 in attorney’s fees with the remainder to
      pay litigation expenses. The remaining award shall be paid at the weekly rate of
      $562.19 so long as Mr. Ray is eligible for permanent and total disability benefits.

   2. The Subsequent Injury and Vocational Recovery Fund retains no liability for
      permanent total disability benefits to Mr. Ray.

   3. Rollins shall pay $2,580.10 to Mr. Ray as reimbursement for his litigation
      expenses.

   4. Dr. Jacob Schwarz shall remain Mr. Ray’s treating physician for his work-related
      back injury. Rollins shall pay for reasonable, necessary, and related medical
      treatment for this injury.

   5. Rollins shall pay costs of $150.00 to the Court Clerk within five business days of
      this order becoming final.

   6. Rollins shall file with the Court Clerk a Statistical Data Form within ten business
      days of this order becoming final.

    7. This Compensation Order is a final adjudication upon the merits of Mr. Ray’s
       claim for benefits. Unless appealed, it shall become final in thirty days.

      ENTERED on July 21, 2021.

                                 _____________________________________
                                 ROBERT DURHAM, JUDGE
                                 Court of Workers’ Compensation Claims

                                     APPENDIX

Technical Record:
          1. Petition for Benefit Determination
          2. Dispute Certification Notice
          3. Amended Scheduling Order
          4. Notice of Compensation Hearing

                                           10
            5.   Mr. Ray’s Exhibit and Witness List
            6.   Rollins’ Exhibit and Witness List
            7.   Rollins’ Pre-Compensation Hearing Statement
            8.   Mr. Ray’s Pre-Compensation Hearing Statement
            9.   SIF’s Pre-Compensation Hearing Statement

Exhibits:
            1.   Mr. Ray’s Submission of Evidence
            2.   Satellite Med’s Medical Records
            3.   Rollins’ Submission of Medical Records
            4.   Mr. Galloway’s Vocational Assessment
            5.   Pain Management Group’s Medical Records
            6.   Mr. Galloway’s Curriculum Vitae
            7.   Dr. Kennon’s Vocational Assessment

                              CERTIFICATE OF SERVICE

       I certify that a copy of the Order was sent as indicated on July 21, 2021.

Name                      Certified   Via     Via    Service sent to:
                           Mail       Fax    Email
Jill Draughon                                  X     JDraughon@hughesandcoleman.com
Charles Pierce                                 X     cepierce@mijs.com
Patrick Ruth                                   X     Patrick.Ruth@tn.gov

                                            _____________________________________
                                            PENNY SHRUM, Court Clerk
                                            WC.CourtClerk@tn.gov

                                              11
                                              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 file-
stamped 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 1 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]

LB-1099 rev. 01/20                                 Page 2 of 2                                        RDA 11082