Court Opinion

ID: 4696198
Source: CourtListenerOpinion
Date Created: 2021-06-16 19:40:56.458213+00
Date Added: 2024-06-11T08:05:57.718603
License: Public Domain

FILED
                                                                                  Jun 09, 2021
                                                                                  07:15 AM(CT)
                                                                               TENNESSEE COURT OF
                                                                              WORKERS' COMPENSATION
                                                                                     CLAIMS

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

 June Ruggieri,                                )   Docket No. 2020-06-1452
            Employee,                          )
 v.                                            )
 Amazon.com, LLC,                              )   State File No. 37474-2020
            Employer,                          )
 And                                           )
 American Zurich Ins. Co.,                     )   Judge Kenneth M. Switzer
             Carrier.                          )

       EXPEDITED HEARING ORDER GRANTING MEDICAL BENEFITS

        This case came before the Court on June 8 for an expedited hearing. June Ruggieri
alleged that she injured her shoulder while working at Amazon.com, LLC. Amazon
initially provided treatment but later denied the claim, asserting that she gave untimely
notice. After the denial, Ms. Ruggieri sought unauthorized treatment with an orthopedist.
She seeks an order designating the orthopedist as the authorized treating physician and
making Amazon pay past and ongoing bills incurred for her treatment and temporary
disability benefits, as well as attorney fees for an alleged wrongful denial.

       For the reasons below, the Court holds Ms. Ruggieri is likely to prevail in a hearing
on the merits that she gave timely notice and suffered an injury arising primarily out of and
in the course and scope of employment. The Court grants her requested relief in part but
denies her request for attorney fees at this time.

                                      Claim History

       Ms. Ruggieri worked night shifts in the Amazon warehouse. She testified that on
Tuesday, May 5, 2020, early in her shift before midnight, as she took down an unexpectedly
heavy package from the top shelf of a rack, the package fell and pulled her right arm
downward. She immediately felt a tear in her right shoulder but continued working. She
returned to work the next evening but asked to leave early due to pain. She testified that
she did not immediately report the injury because she thought her condition might improve
after resting over her weekend.

       Ms. Ruggieri testified that she later told two separate “learning ambassadors,” also
known as “line leaders” or “shift leads,” about the injury. Although the learning
ambassadors are continuously assigned different duties and personnel to manage, they wear
vests that identify them as supervisors.

      According to Ms. Ruggieri, on Saturday, May 9, as she began her shift, a learning
ambassador named “Donna” asked why she left early a few nights ago, “and I told her it
was because I was hurt the night before.”

        Then on May 19, she told a learning ambassador named “Ruchika,” also known as
“Rena,” about her injury. Ms. Ruggieri testified that she was struggling to drag a box with
her left arm, and Ruchika asked if she needed help. She told Ruchika she had injured her
arm and was worried that it would be a workers’ compensation case. To Ms. Ruggieri’s
knowledge, Amazon did not complete a report of injury at that time.

      Ms. Ruggieri called Amazon’s “Dial-a-Doc” on May 22. Afterward, she contacted
an urgent care clinic, which refused to see her because her injury occurred at work. She
asked her shift manager, “Trevia,” to file a claim on May 24, and the next morning she
completed Amazon’s “Associate First Report of Injury.”1

       Ms. Ruggieri testified that no one answers the phone at Amazon. On cross-
examination, she stated that human resources staff rarely work night shifts, and she could
not see them during the day because associates are not allowed on the premises unless they
are scheduled to work. Ms. Ruggieri acknowledged that she did not email Trevia or any
other manager but explained that she did not know Trevia’s email address and that, in her
experience, managers do not respond to email.

       As for authorized treatment, on May 25, Amazon sent Ms. Ruggieri to a nearby
emergency room. She testified that providers there took her off work, and she did not work
for a week. Later, Ms. Ruggieri chose Dr. Harold Nevels from a panel. She saw him five
times in the coming month. Dr. Nevels initially diagnosed a shoulder sprain, placed her
on restricted duty, and ordered physical therapy. According to Ms. Ruggieri, Amazon
never authorized the physical therapy.

     Dr. Nevels completed a “Healthcare Provider Request for Information Form” for
Amazon in mid-June, checking a box that the injury is “work-related.” Amazon objected

1
    Ms. Ruggieri mistakenly wrote on the form that her injury occurred on May 7.
to the admissibility of this document, contending that it contains unauthenticated hearsay
and is an employment record, not a medical record.

       The Court admitted the document. Tennessee Code Annotated section 50-6-
239(c)(1) states that whenever the administrator has adopted an evidentiary rule that
conflicts with the Rules of Evidence, the administrator’s rule applies. Tennessee
Compilation Rules and Regulations 0800-02-21-.16(2)(b) (August, 2019) states that signed
medical records are admissible.

       As to whether this particular document is a medical record, Tennessee Code
Annotated section 63-2-101 broadly defines “medical records” in relevant part as “all
medical histories, records, reports and summaries.” The Appeals Board has held that
“medical reports signed by a physician are admissible. See Morgan v. Macy’s, 2016 TN
Wrk. Comp. App. Bd. LEXIS 39, at *21 (Aug. 31, 2016) (Trial court did not err by
admitting a signed utilization review report into evidence).

       Although the document at issue is a form created by Amazon and was not generated
by the doctor or the Bureau, the Court reasonably infers that Dr. Nevels completed it at
Amazon’s request. It reports/summarizes detailed medical information about Ms.
Ruggieri’s condition and necessary work accommodations, including whether she was
prescribed medication. Dr. Nevels noted the physical therapy and orthopedic referrals on
the form. Considering the predominance of medical rather than employment information
conveyed within the two-page document, the Court finds this is a medical record and is
therefore admissible under the administrator’s rule.

      On June 15, 22 and 29, Dr. Nevels referred Ms. Ruggieri to orthopedist Dr. Kyle
Joyner. The June 15 notes stated that Dr. Nevels referred her to Dr. Joyner “for second
opinion,” but later the notes clarified Dr. Nevels’s intention: “I would like to have Dr.
Joyner re evaluate [sic] this case and assume management.” Dr. Nevels maintained Ms.
Ruggieri’s work restrictions throughout her treatment.

       Amazon never authorized the referral or offered a panel of orthopedists. Instead, it
denied the claim on July 2, asserting Ms. Ruggieri gave a “late report” of her injury as the
sole basis for the denial. Afterward, Ms. Ruggieri continued working.

        Ms. Ruggieri saw Dr. Joyner on her own in March 2021. He suspected rotator cuff
pathology and ordered an MRI, which confirmed a right-shoulder full thickness rotator cuff
tear. Dr. Joyner performed surgery, but his notes are silent as to work restrictions. Ms.
Ruggieri said he assigned restrictions in a letter she gave to Amazon. She worked a few
shifts until her last day at work on April 22. She is not currently working.

      In a letter from Ms. Ruggieri’s attorney, Dr. Joyner checked “yes” when asked
whether “[w]ithin a reasonable degree of medical certainty and considering all causes . . .
the right shoulder condition for which you are treating Ms. Ruggieri [is] more than 50%
related to her on the job injury at Amazon in May of 2020.” He noted, “Likely secondary
to lowering a heavy box from an overhead position.” Amazon offered no contrary medical
causation opinion.

        Ms. Ruggieri further testified that she incurred medical expenses totaling $1,661.96
for visits with Dr. Joyner, surgery and physical therapy. However, the Court did not admit
the bills or a spreadsheet summarizing them into evidence, based on Eaves v. Ametek, 2018
TN Wrk. Comp. App. Bd. LEXIS 53, at *8 (Sept. 14, 2018). In that case, the Appeals
Board held that medical bills were inadmissible, when not signed by a physician, not
accompanied by a proper certification, not attached to an affidavit from a medical provider
attesting to their accuracy or completeness, and the employee offered no proof that the
medical bills were reasonable, necessary, or causally-related to the work accident.

                        Procedural history and motion to continue

       Amazon moved for a continuance before the hearing. The Court heard argument on
the motion on the morning of the hearing. A review of past events and their timing provides
a helpful context for the Court’s decision to deny the motion.

      Ms. Ruggieri, self-represented at the time, filed her petition for benefit
 determination in September 2020. A dispute certification notice was issued on February
 10, 2021, that included compensability as an issue. Notably, Amazon submitted a
 February 2 letter to the mediator outlining the issues, including whether the injury arose
 primarily from employment.

       On March 30, Ms. Ruggieri filed a request for expedited hearing but not an affidavit
 or declaration. On April 6, her attorney filed a notice of appearance, and on April 9, he
 filed her declaration.

        The Court held a pretrial hearing on April 19, where the parties agreed to a June 8
 trial date. On May 21, Ms. Ruggieri filed medical records from Dr. Joyner, and on May
 24, Amazon filed its pre-hearing brief.

      On May 28, Amazon moved for a continuance to obtain an employer’s examination
and depose Dr. Joyner.

       As grounds, Amazon argued that the hearing request was improper because the
declaration was not filed at the same time. Tennessee Compilation Rules and Regulations
0800-02-21-.15(1) reads, “A request for expedited hearing must be accompanied by an
affidavit or a T.R.C.P. Rule 72 declaration[.]” However, the Appeals Board has held, “In
the context of the regulation addressing expedited hearings, we conclude that
‘accompanied by’ contemplates that the supporting documentation is to be filed in
association with the request for hearing and does not necessarily require the documentation
to be filed concurrently or contemporaneously with the request for hearing.” Smith v. La-
Z-Boy, 2017 TN Wrk. Comp. App. Bd. LEXIS 52, at *9-10 (Aug. 31, 2017).

       Amazon additionally argued that Dr. Joyner’s medical records were not filed with
the Court with the request for expedited hearing as required by the rules. The Court is
unpersuaded, applying the same logic from Smith: “accompanied by” does not necessarily
require the documentation to be filed concurrently or contemporaneously with the hearing
request. Moreover, the April record recommending surgery did not exist when she filed
her request. Once Ms. Ruggieri’s attorney became involved in the case, he disclosed
records as they were received.

       Amazon additionally contends that it did not have the opportunity to question and/or
cross-examine Dr. Joyner regarding his findings and opinions, and it would like to obtain
an employer’s examination.

       The Court rejects these arguments. Amazon received Dr. Joyner’s records on May
21. Amazon has been aware of compensability and medical causation as issues in this case
since at least February 2. Its attorney voiced no concerns regarding the need for an
employer’s examination at the pretrial hearing, where she agreed to the June 8 hearing date.

       The Appeals Board has reminded, “trial courts have been charged with controlling
the pace of litigation through the use of supervision and docket management which will
ensure efficient disposition of civil cases.” Smith v. The Newman Grp., LLC, 2015 TN
Wrk. Comp. App. Bd. LEXIS 30, at *9 (Sept. 21, 2015). Here, the Court finds no good
cause to continue the hearing. See Tenn. Comp. R. and Regs. 0800-02-21-.11(8) (August,
2019).

                        Findings of Fact and Conclusions of Law

       At an expedited hearing, Ms. Ruggieri must show that she is likely to prevail at a
hearing on the merits. See Tenn. Code Ann. § 50-6-239(d)(1) (2020); McCord v.
Advantage Human Resourcing, 2015 TN Wrk. Comp. App. Bd. LEXIS 6, at *7-8, 9 (Mar.
27, 2015).

                                           Notice

       Notice is the threshold issue in this case. When lack of notice is raised as a defense,
the burden is on the employee to show that notice was given, the employer had actual
notice, or the failure to give notice was reasonable under the circumstances. Hosford v.
Red Rover Preschool, 2014 TN Wrk. Comp. App. Bd. LEXIS 1, at *15 (Oct. 2, 2014).
        The Workers’ Compensation Law provides that an injured employee “shall,
immediately upon the occurrence of an injury, or as soon thereafter as practicable, give . .
. to the employer who has no actual notice, written notice of the injury . . . within fifteen
(15) days after the occurrence of the accident, unless reasonable excuse for failure to give
the notice is made to the satisfaction of the tribunal[.]” Tennessee Code Annotated section
50-6-201(a)(1).

        Further, “[n]o 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 . . .
that the employer was prejudiced by the failure to give the proper notice, and then only to
the extent of the prejudice.” Id. at § 50-6-201(a)(3). In addition, “The notice shall be given
personally to the employer or to the employer’s agent or agents having charge of the
business at which the injury was sustained by the employee.” Id. at § 50-6-201(a)(4).

      Here, Ms. Ruggieri credibly testified that she gave notice of her injury to Donna on
May 9 and Ruchika on May 19. Her understanding of their roles, their job titles of learning
ambassador, shift lead, and line lead, and their vests setting them apart from other workers,
caused Ms. Ruggieri to reasonably believe they had “charge” to assist her. The statute
makes no distinction regarding actual supervision at the time of the injury or report. When
Donna and Ruchika did not complete paperwork to initiate the claim, Ms. Ruggieri called
Amazon’s “Dial-a-Doc” on May 22 and notified her shift manager on May 25 and
completed a written first report. Amazon did not contravene this testimony.

       The Court finds the conversations with Donna and Ruchika provided notice within
the statutory fifteen days. She contacted “Dial a Doc” and ultimately gave the shift
manager, Trevia, written notice. The Court finds the conversations with Donna and
Ruchika were a reasonable excuse for the failure to give written notice within fifteen days.

       Amazon argued it was prejudiced by Ms. Ruggieri’s failure to give timely notice.
The Court disagrees. The notice requirement contained in the statute “exists so that an
employer will have an opportunity to make a timely investigation of the facts while still
readily accessible, and to enable the employer to provide timely and proper treatment for
an injured employee.” Hosford, at *15.

       On this record, the Court finds no prejudice to Amazon. Amazon argued, without
medical proof, that Ms. Ruggieri working in the days immediately after her injury, rather
than receiving medical treatment, likely worsened her alleged injury. However, “parties
and their lawyers cannot rely solely on their own medical interpretations of the evidence
to successfully support their arguments.” Lurz v. Int’l Paper Co., 2018 TN Wrk. Comp.
App. Bd. LEXIS 8, at *16 (Feb. 14, 2018). Moreover, Amazon provided immediate
emergency treatment on May 25, the same day Ms. Ruggieri told Trevia that she was
injured. Amazon offered no proof of how a delay in treatment from May 5 through May
25 hampered its investigation. Ms. Ruggieri filed her petition last September. From that
point forward, Amazon has been able to engage in formal discovery, including taking her
deposition, but it has not.

        In sum, the Court holds that Ms. Ruggieri has satisfied her burden. She has shown
she is likely to prevail at a hearing on the merits that Amazon had timely notice and that
she had a reasonable excuse for her failure to give timely written notice.

                        Injury arising primarily from employment

     Next, Ms. Ruggieri must show that she suffered an “injury” as defined in the
Workers’ Compensation Law.

       Tennessee Code Annotated section 50-6-102(14) defines “[i]njury” to mean “an
injury by accident . . . arising primarily out of and in the course and scope of employment,”
that causes the need for medical treatment. An injury “arises primarily out of and in the
course and scope of employment” only if it has been shown by a preponderance of the
evidence, and to a reasonable degree of medical certainty, that the employment
“contributed more than fifty percent” in causing the injury, considering all causes. Id. at §
50-6-102(14)(B)-(C).

        As to the above definition and medical causation, the Court finds that Dr. Joyner
gave the opinion that “within a reasonable degree of medical certainty and considering all
causes,” Ms. Ruggieri’s shoulder condition is “more than 50% related to her on the job
injury at Amazon in May of 2020.” He explained the injury was “[l]ikely secondary to
lowering a heavy box from an overhead position,” which coincides with Ms. Ruggieri’s
description of how she became injured. Moreover, Dr. Nevels, an authorized treating
physician, completed a form at Amazon’s request where he checked a box characterizing
the injury as “work-related.” Amazon offered no contrary medical proof.

        While neither doctor used the complete statutory definition in their opinions, their
word choice comes very close. A physician need not use particular words or phrases
included in the statutory definition of “injury” to show the requisite medical proof to
succeed at trial, but rather what is necessary is sufficient proof from which the trial court
can conclude that the statutory requirements of an injury as defined in section 50-6-102(14)
are satisfied. Panzarella v. Amazon.com, Inc., 2017 TN Wrk. Comp. App. Bd. LEXIS 30,
at *13-15 (May 15, 2017) (Emphasis in original). In addition, Dr. Nevels’s opinion that
Ms. Ruggieri’s injury is “work-related” is presumed correct. See Tenn. Code Ann. § 50-
6-102(14)(E) (The causation opinion of a physician chosen from a panel is presumed
correct). The Court concludes that Ms. Ruggieri is likely to show at a hearing on the merits
that she suffered an injury arising primarily from employment.
                   Requested relief and Compliance Program referrals

       Ms. Ruggieri has requested that the Court designate Dr. Joyner as the authorized
treating physician and order payment of past medical bills.

       The Appeals Board has written, “It is a fundamental tenet of Tennessee workers’
compensation law that an employer is responsible for furnishing an injured worker ‘such
medical and surgical treatment . . . made reasonably necessary by accident as defined in
this chapter.’” Barrett v. Lithko Contracting, 2016 TN Wrk. Comp. App. Bd. LEXIS 93,
at *5 (Dec. 8, 2016), citing Tenn. Code Ann. § 50-6-204(a)(1)(A). Further, “[a]n employer
who elects to deny a claim runs the risk that it will be held responsible for medical benefits
obtained from a medical provider of the employee’s choice and/or that it may be subject to
penalties for failure to provide a panel of physicians and/or benefits in a timely manner.”
Barrett, at *8.

        Applying these principles, Dr. Nevels referred Ms. Ruggieri to Dr. Joyner three
times, on June 15, 22 and 29. “In circumstances where an authorized physician has referred
the injured worker to a particular specialist, ‘[t]he employer shall be deemed to have
accepted the referral, unless the employer, within three (3) business days, provides the
employee a panel of three (3) or more independent reputable physicians.’” Barrett, at *6,
citing Tenn. Code Ann. § 50-6-204(a)(3)(A)(ii). Amazon ignored the referrals and this
clear statutory pronouncement, and it failed to either offer a timely panel of orthopedists
or authorize treatment with Dr. Joyner. Amazon took a deliberate risk, and now it must
bear the consequences.

       The Court orders that Amazon provide medical benefits with Dr. Joyner as the
authorized treating physician and shall authorize any recommended treatment. As to
previously incurred expenses, Ms. Ruggieri has not shown entitlement on this record, and
the request is denied at this time.

        Ms. Ruggieri additionally sought temporary disability benefits for four days after
the injury. Amazon correctly argued that the Workers’ Compensation Law does not allow
compensation for the first seven days of injury. Tenn. Code Ann. § 50-6-205(a).

       Ms. Ruggieri also requested temporary benefits from April 23 to the present, and
ongoing. To receive temporary total disability benefits, an employee must prove (1) total
disability from working as the result of a compensable injury; (2) a causal connection
between the injury and the inability to work; and (3) the duration of the period of disability.
Shepherd v. Haren Constr. Co., Inc., 2016 TN Wrk. Comp. App. Bd. LEXIS 15, at *13
(Mar. 30, 2016). Here, Amazon argued that Ms. Ruggieri did not offer proof that Dr.
Joyner took her off work, post-surgery. The Court agrees. On this record, she has not
shown “total disability,” so she is not likely to prevail on her request for temporary
disability benefits at this time.
        She further seeks attorney fees. Tennessee Code Annotated section 50-6-226(d)(1)
states that the court may award fees when the employer “[w]rongfully denies a claim[.]”
A decision to award attorney’s fees at an interlocutory stage of a case should be made “only
in extremely limited circumstances.” Travis v. Carter Express, Inc., 2019 TN Wrk. Comp.
App. Bd. LEXIS 25, at *10 (June 24, 2019) (Emphasis in original). Further, when an
employer denies a claim or refuses to initiate benefits “based on a reasonable interpretation
of the facts available to it at the time the claim is denied, even if that denial is later found
to be wrongful, the court should delay an award of attorney’s fees until the litigation has
run its course and there is no longer a question as to the compensability of the claim[.]” Id.
at *14.

        Considering these legal principles, the Court finds it appropriate to delay a fee award
until this case has run its course and compensability is no longer a question. In light of
Amazon’s intention to obtain an employer’s examination and to depose Dr. Joyner, the
compensability of the claim remains a viable issue for the compensation hearing.

      As a final matter, the Court refers this case to the Compliance Program to investigate
and potentially penalize Amazon for the following.

       ◼ Tennessee Compilation Rules and Regulations 0800-02-01-.06(8) (May, 2018)
         provides that where “the authorized treating physician, selected by the employee
         from an initial panel, refers the employee for specialized care, the employer shall
         be deemed to have accepted the referral, unless the employer, within three (3)
         business days, provides a panel of three (3) or more independent reputable . . .
         specialty practice groups to the employee[.]” The Court finds that Amazon did
         not accept Dr. Nevels’s referrals to Dr. Joyner to assume treatment, nor did it
         offer a panel of orthopedists.

       ◼ Tennessee Compilation Rules 0800-02-14-.04(6) (August, 2018) states that
         “Decisions on compensability shall be made by the adjusting entity within
         fifteen (15) calendar days of the verbal or written notice of injury.” The Court
         finds that Amazon received notice of Ms. Ruggieri’s alleged injury in May, but
         it denied the claim raising a notice defense on July 2, after the fifteen-day
         timeframe.

   IT IS, THEREFORE, ORDERED AS FOLLOWS:

   1. Amazon shall provide medical benefits with Dr. Kyle Joyner as the authorized
      treating physician. It shall promptly pay any bills incurred for treatment provided
      on or after the date of this order.
   2. This case is set for a status hearing on September 13, 2021, at 9:00 a.m. Central
      Time. You must dial 615-532-9552 or 866-943-0025 toll-free. Failure to call might
      result in a determination of the issues without your participation.

   3. This case is referred to the Compliance Program for consideration of the imposition
      of penalties regarding Amazon’s failures to timely authorize treatment with a
      referral physician or to offer a panel of specialists, and to make a decision on
      compensability within fifteen days of notice of the injury.

   4. 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 may result in a penalty assessment for
      non-compliance. For questions regarding compliance, please contact the Workers’
      Compensation Compliance Unit by email at WCCompliance.Program@tn.gov.

                                  ENTERED June 16, 2021.

                                  ________________________________________
                                  JUDGE KENNETH M. SWITZER
                                  Court of Workers’ Compensation Claims

                                       Appendix

Evidence:
1. Ms. Ruggieri’s Declaration and attachments (Ex. B for identification only)
2. Employee’s Medical Records
3. Medical bills, Dr. Joyner (Identification only)
4. First Report of Injury
5. Associate First Report of Injury
6. (Withdrawn by the parties’ agreement)
7. Notice of Denial

Technical Record:
1. Petition for Benefit Determination
2. Dispute Certification Notice and Employer’s additional issues
3. Request for Expedited Hearing
4. Pretrial Hearing Order
5. Employer’s Response to Hearing Request
6. Motion to Continue
7. Employee’s Response to Motion to Continue

Stipulation:
Ms. Ruggieri’s average weekly wage is $823.68, and her compensation rate is $549.12 for
purposes of this hearing, subject to modification by agreement of the parties or order of the
court, until a wage statement is filed.

                             CERTIFICATE OF SERVICE

       I certify that a copy of this Order was sent as indicated on June 16, 2021.

Name                   Certified    Regular    Email     Sent to
                       Mail         mail
J. Allen Brown,                                   X      allen@jallenbrownpllc.com
employee’s attorney
Kristen Stevenson,                                X      Kcstevenson@mijs.com
employer’s attorney                                      telett@mijs.com
                                                         ssshell@mijs.com
Compliance                                        X      WCCompliance.Program@tn.gov
Program

                                   _______________________________________
                                   Penny Shrum
                                   Clerk, Court of Workers’ Compensation Claims
                                   WC.CourtClerk@tn.gov
                                              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