Court Opinion

ID: 6326554
Source: CourtListenerOpinion
Date Created: 2022-03-24 16:24:28.464827+00
Date Added: 2024-06-11T09:22:13.872727
License: Public Domain

FILED
                                                                                  Mar 22, 2022
                                                                                  09:47 AM(CT)
                                                                                TENNESSEE COURT OF
                                                                               WORKERS' COMPENSATION
                                                                                      CLAIMS

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

 ROBERT J. BLANK,                             )         Docket Nos. 2018-07-0725
           Employee,                          )
 v.                                           )
 ESTES EXPRESS LINES,                         )
           Employer,                          )
 and,                                         )         State File No. 68179-2018
 NEW HAMPSHIRE INS. CO.,                      )
           Carrier,                           )
 And                                          )
 ABIGAIL HUDGENS, as                          )
 ADMINISTRATOR of the BUREAU                  )         Judge Allen Phillips
 OF WORKERS’ COMPENSATION,                    )
 SUBSEQUENT INJURY AND                        )
 VOCATIONAL RECOVERY FUND.                    )

                               COMPENSATION ORDER

       Mr. Blank requested benefits for an August 30, 2018 left-shoulder injury. The Court
held a Compensation Hearing on February 23, 2022 and awards him benefits as described
below.
                                    History of Claim

        Mr. Blank worked for Estes as a truck driver, which required some manual labor.
On August 30, 2018, he injured his left shoulder in a forklift accident. Estes provided
medical treatment from orthopedic surgeon Dr. Jason Hutchison, who surgically repaired
tears in the biceps tendon and rotator cuff. On May 15, 2019, Dr. Hutchison released Mr.
Blank to return to work without restrictions and assessed a two-percent permanent
impairment rating. Mr. Blank later filed a timely Petition for Benefit Determination for that
injury.
      Mr. Blank returned to work, and on May 29, 2019, he lifted a table that weighed
approximately 400 pounds. He felt pain in his left shoulder and reported the incident to his

                                             1
supervisor. Estes completed a First Report of Injury and provided follow-up medical
treatment with Dr. Hutchison.
      Dr. Hutchison recorded Mr. Blank’s history of lifting the table. He said that incident
was a new injury, separate and apart from the original, and he assigned restrictions that
prevented Mr. Blank from working.
        Dr. Hutchison referred Mr. Blank to his partner, Dr. Adam Smith, for an opinion
regarding another surgery. Dr. Smith ultimately performed a second shoulder surgery, and
Dr. Hutchison testified that Mr. Blank would not have needed that surgery but for the table-
lifting incident. He further testified that Mr. Blank could have returned to work within the
restrictions Dr. Smith placed after the second surgery.
       Dr. Hutchison also reviewed surveillance photos obtained by Estes after Dr. Smith’s
surgery that showed Mr. Blank unloading forty-pound bags of mulch from a truck. Dr.
Hutchison said that activity, particularly images showing Mr. Blank lifting with
outstretched arms, suggested he could return to work, including driving a truck.
        Dr. Smith testified Mr. Blank told him he “initially was doing okay, but then had
another injury and had recurrent pain.” Dr. Smith did not diagnose a new tear in the
shoulder but instead called his condition a “strain.” Dr. Smith said the table-lifting was a
“new injury.” However, he noted that Mr. Blank did not tell him about lifting the table at
the first visit; rather he gave an initial history of only minimal activity, which Dr. Smith
said, “doesn’t make sense.”
        During surgery, Dr. Smith saw “degeneration of the shoulder,” meaning the repaired
biceps tendon “looked worse,” and the shoulder “cartilage had fallen apart.” He said a
rotator cuff repair like Dr. Hutchison performed can “create a cascade of events that leads
to deterioration” of the shoulder. He said he did not know if that deterioration was caused
by the table-lifting but did say that the lifting led to the strain. Dr. Smith noted, “[A]ll I can
say is . . . [Mr. Blank] was hurting more substantially and . . . had substantial increase in
pain” after lifting the table.
        Dr. Smith assessed a four-percent permanent impairment rating, with two percent
of that rating for the original injury of August 2018, agreeing with Dr. Hutchison.
        Mr. Blank saw Dr. Samuel Chung in July 2020 for an independent medical
evaluation. Dr. Chung recorded a history of the August 2018 forklift accident; he did not
mention the table-lifting incident. Instead, Dr. Chung said Mr. Blank returned to work after
Dr. Hutchison released him and “continued to work in his best capacity,” but then he
returned to Dr. Hutchison for “ongoing complaints of persistent left shoulder functional
deficit.” Dr. Chung assessed a seven-percent permanent impairment rating and related it to
the August 2018 injury.

                                                2
        On July 26, 2021, Mr. Blank filed a Petition for Benefit Determination for the May
29, 2019 table-lifting incident. He claimed July 26, which was the day the parties deposed
Dr. Hutchison, was the first time he became aware that he had a new injury. Because Estes
last paid benefits related to the May 29, 2019 injury on May 26, 2020, it filed a Motion for
Summary Judgment on statute of limitations grounds. Estes said Mr. Blank filed his second
petition more than one year after it last paid benefits. In contrast, Mr. Blank pointed to Dr.
Smith’s testimony that a “cascade of events” might lead to deterioration of the shoulder,
meaning he did not sustain a new injury.
       The Court granted Estes’s motion, holding that Mr. Blank did not discover a new
injury when Dr. Hutchison was deposed but instead knew of a new injury when he lifted
the table. Thus, the Court dismissed Mr. Blank’s petition related to the May 29, 2019 date
of injury but found the August 2018 injury remained at issue.
       The parties proceeded to this Compensation Hearing for the original August 2018
injury. In support of his claim for permanent total disability, Mr. Blank testified he was
sixty-four years old and had only an eighth-grade education. His work history was
primarily as a truck driver. He recounted the August 2018 forklift accident and confirmed
that Dr. Hutchison returned him to work in May 2019. He said he then “reinjured” and
“hurt his shoulder again” when lifting the table.
        Mr. Blank said Estes terminated him because of Dr. Smith’s restrictions. He also
claimed continued problems with range of motion and lack of strength in his shoulder, but
he admitted the surveillance photos showed him unloading forty-pound bags of mulch. He
additionally said he drew unemployment after Dr. Smith released him, and he understood
that meant he held himself out as being able to work. He explained he applied for and was
offered another truck-driving job, but the new employer revoked the offer when it learned
of his restrictions. He has not worked since leaving Estes.
       In opposition, Estes presented the testimony of its terminal manager, Billy Oliver,
who has twenty-six years of experience in the trucking industry. Mr. Oliver said a driver
could work some jobs with a fifty-pound restriction, and someone with dispatching
experience, like Mr. Blank, could also work as a dispatcher. Mr. Oliver confirmed Mr.
Blank reported a new injury after lifting the table and that Estes completed a First Report
of Injury.
       Based on this evidence, Mr. Blank argued he was permanently and totally disabled,
relying on his limited education, restrictions, and failed attempts to return to work. 1 Mr.
Blank also argued that the May 2019 table-lifting incident did not cause his disability, but
he instead related it to his 2018 injury. He again pointed to Dr. Smith’s testimony regarding
a cascade of events that caused deterioration after the first surgery. Thus, Mr. Blank argued

1
 The parties presented extensive argument regarding whether Mr. Blank was totally disabled, the period
for which he might receive permanent total benefits, and the apportionment of those benefits between Estes
and the Subsequent Injury Fund. Given the Court’s findings below, it need not recite those arguments.
                                                    3
that, if the Court did not find him totally disabled, it should award him increased benefits
under Tennessee Code Annotated section 50-6-307(3)(B) (2021), because he could no
longer work due to his original injury.
       Mr. Blank admitted Estes paid him his regular salary during the same period that
Estes’s carrier paid him temporary total disability payments. He confirmed that he signed
an agreement to pay back the temporary benefits, and that agreement was placed in
evidence. It stated that Mr. Blank agreed to repay a total of $10,037.59 in temporary
benefits. He produced a personal check for $7,161.67, representing one payment of the
indebtedness. Mr. Blank also testified that he receives Social Security Old Age benefits of
$1,659.10 per month after taxes.
       For its part, Estes argued that Mr. Blank was not totally disabled but instead only
had a two-percent permanent partial disability. It also argued Mr. Blank could not recover
any increased benefits because his loss of employment was related to the May 2019 table
incident, not the original injury. Finally, it asserted its entitlement to an offset of Social
Security benefits against any award and for a credit for the overpayment of temporary total
disability.
       The Subsequent Injury Fund denied Mr. Blank was totally disabled.
       In a post-trial submission, Mr. Blank argued that Braden v. Mohawk Industries, Inc.,
2022 TN Wrk. Comp. App. Bd. LEXIS 11 (Mar. 1, 2022) supports his position. There, the
employee injured his ankle and then returned to work. Later, while merely walking, his
ankle popped, and he sought additional benefits. The Appeals Board held that the direct
and natural consequences rule allowed recovery. That rule provides that a later injury,
whether an aggravation of the original injury or a new and distinct one, is compensable if
the direct and natural result of the earlier compensable injury. Moreover, all medical
consequences and sequelae that flow from the original injury are compensable. Id. at *10.
Mr. Blank said that holding was “substantially on all fours” with his case.

                        Findings of Fact and Conclusions of Law

      Mr. Blank must prove all elements of his case by a preponderance of the evidence.
Tenn. Code Ann. § 50-6-239(c)(6).

                                       Date of Injury

        Mr. Blank first argued that his disability after the May 2019 table-lifting incident
was a natural and direct consequence of the August 2018 injury, meaning he could recover
either permanent total disability or enhanced benefits because of it. The Court respectfully
disagrees.

       In Braden, the Appeals Board held the direct and natural consequences rule provides

                                              4
that all medical sequelae that flow from an injury are compensable. Here, Mr. Blank relied
on Dr. Smith’s testimony to argue that his disability flowed from the original 2018 injury.
However, that argument ignores both Dr. Hutchison’s and Dr. Smith’s testimony that the
table incident was a new injury.

       Though Dr. Smith said the original injury, and treatment of it, can lead to a cascade
of events causing deterioration, he also said Mr. Blank’s history of only minimal activity
upon returning to work in May 2019 was inconsistent with lifting a 400-pound table.
Further, Mr. Blank had an increase in pain and disability because of the table incident. The
Court finds that Mr. Blank returned to work without restrictions, then had increased
disability leading to further surgery because of a specific traumatic injury. Contrast these
facts with Braden, where the employee returned to work and was merely walking when his
ankle popped with no new intervening trauma.

       Thus, the Court holds the direct and natural consequences rule does not apply.

                              Extent of Permanent Disability

       In assessing Mr. Blank’s permanent disability from the 2018 injury, the Court may
consider a number of factors, including his medical impairment, education, age, training,
and job opportunities. Braden, at *21. Additionally, the Court should consider Mr. Blank’s
own assessment of his physical condition as to ability to return to work. Id. at *21-22. The
extent of Mr. Blank’s vocational disability is a question of fact resolved by a review of
both the lay testimony and medical evidence. Id. at *22.

       Mr. Blank claimed he was permanently and totally disabled. The Court disagrees.
An employee may recover permanent total disability benefits only if his injury totally
incapacitates him from working. See Tenn. Code Ann. § 50-6-207(4)(B). Here, the
preponderance of the evidence shows Mr. Blank is not totally incapacitated. He has a fifty-
pound lifting restriction but no other limitation. He sought another job and drew
unemployment benefits, both suggesting his own belief that he could work. Further, Estes
obtained surveillance showing Mr. Blank’s ability to unload many forty-pound bags of
mulch, a feat of manual labor inconsistent with total incapacitation. Both Drs. Hutchison
and Smith believed Mr. Blank could return to work full-time including driving a truck.
Thus, the Court holds Mr. Blank is not permanently and totally disabled, and his claim
against the Subsequent Injury Fund is dismissed.

       However, Mr. Blank did prove he sustained a permanent partial disability. The
parties agreed that Dr. Hutchison assessed a two-percent impairment rating. Likewise, Dr.
Smith attributed two percent of Mr. Blank’s total rating to the injury in question. The Court
accepts the two-percent rating. The Court gives no weight to Dr. Chung’s rating, as he saw
Mr. Blank after the May 2019 table-lifting incident but neither mentioned it nor discussed
how it may have affected the examination findings. These omissions undermine the rating’s

                                             5
validity.

       Thus, the Court holds Mr. Blank sustained a two-percent permanent partial
disability and is entitled to an original award of benefits equal to that rating, or nine weeks
of benefits. See Tenn. Code Ann. § 50-6-207(3)(A).

       Mr. Blank is entitled to the original award regardless of his employment status at
the time of his maximum medical improvement. Batey v. Deliver This, Inc., 2018 TN Wrk.
Comp. App. Bd. LEXIS 2, at *8 (Feb. 6, 2018). However, this does not end the inquiry. If
Mr. Blank was not working at the end of the initial nine-week period, or if he was not
earning the same or greater wage as he was when injured, then he might qualify for
increased benefits “if appropriate.” Tenn. Code Ann. § 207(3)(B). Here, Mr. Blank might
receive increased benefits because he was over age forty and lacked a high school
education. Id.

       In deciding if Mr. Blank is entitled to those increased benefits, the Court must
determine whether he had a “meaningful return to work.” Lasser v. Waste Management,
Inc., 2018 TN Wrk. Comp. App. Bd. LEXIS 20, at *15 (May 24, 2018). The Court must
assess the reasonableness of Estes in attempting to return him to work and the
reasonableness of Mr. Blank in either failing to return or remain at work. Id. If an injured
worker is unable to continue working because of an injury, no meaningful return to work
has occurred in most circumstances. But, if the employee returns to work and then stops
due to reasons unrelated to the injury, then he has made a meaningful return to work. Id. at
*16-17.

        Here, Mr. Blank returned to work after the August 2018 injury but then left after the
table-lifting incident. He left employment at Estes because of that later event, not because
of the injury at issue, and the Court holds he cannot receive any increased benefits.

       This holding is consistent with Brewer v. Lincoln Brass Works, Inc., 991 S.W.2d
226 (Tenn. 1999), where the employee sustained a compensable injury and afterwards
returned to work. He received an initial award of permanent partial disability benefits
limited to the then-applicable statutory cap. The employee then reinjured his back, had
surgery, and was assessed additional impairment. He was unable to continue working, so
he sought enlargement of his previous award. Id. at 227-228.

       The Tennessee Supreme Court held that a request to enlarge a previous award “is
not the appropriate vehicle to use when a worker sustains additional injuries or additional
anatomical impairment.” Id. at 229. Instead, an enlargement is proper only when the injured
worker returns to work but is later forced to stop because of the original injury. Conversely,
if an employee later sustains additional impairment, whether by a later injury or
aggravation of the original injury, then the employee must file a new claim. Id. Mr. Blank
did not file a timely new claim and cannot recover increased benefits.

                                              6
       It follows then that Mr. Blank is entitled to permanent partial disability benefits
equal to his two-percent permanent partial impairment rating, or nine weeks of benefits.

                            Calculation of Permanent Partial Disability

      To calculate Mr. Blank’s award, the Court must address the Social Security offset
and any credit Estes may receive for overpayment of temporary total disability.

       Tennessee Code Annotated section 50-6-207(4)(A)(i) provides that payments of
permanent total disability benefits shall be reduced by the amount of any Social Security
Old Age benefits attributable to employer contributions. In McCoy v. T.T.C. Ill., Inc., 14
S.W.3d 734, 737 (Tenn. 2000), the Tennessee Supreme Court held that the reduction
applies to employees over age sixty who suffer injuries to the body as a whole and are
awarded either permanent total or permanent partial disability benefits. The Court found
the statute was intended to provide a fifty-percent offset of the total amount of Social
Security Old Age benefits received by the employee. Id. at 738.

       Here, Mr. Blank was over age sixty at the time of his August 2018 injury, and the
Court has found he sustained a permanent partial disability.2 He receives $1,659.10 per
month in Social Security Old Age Benefits, or $387.87 per week. Fifty percent of those
benefits is $191.44. ($1,659.10 x 12 ÷ 52 x 50%). The parties stipulated Mr. Blank’s
compensation rate was $703.66 per week. So, after a reduction of $191.44, his adjusted
weekly rate for benefits is $512.22 and, at that adjusted rate, a two-percent permanent
disability equals $4,609.98.

       As to the claimed temporary total overpayment, the parties agreed Estes’s carrier
paid Mr. Blank $10,037.59 for temporary total disability during a period that Estes paid his
regular salary. Mr. Blank agreed to repay those benefits. The evidence showed Mr. Blank
repaid Estes $7,161.67 via a personal check, but no other evidence of repayments is in the
record. Thus, the Court holds Estes is entitled to a remaining credit of $2,875.92 for
overpayment of temporary total disability benefits. ($10,037.59 - $7,161.67).

        When applying the credit for overpayment to Mr. Blank’s adjusted permanent
partial disability award, he is entitled to permanent partial disability benefits of $1,734.06.

2
  At the time McCoy was decided, section 50-6-207(4)(A)(i) provided that permanent total disability would
be paid to an employee injured over age sixty until that employee reached age sixty-five, a maximum period
of 260 weeks. That section now reads those benefits will be paid to an employee injured after age sixty
until he becomes eligible for full Old Age Benefits. However, the current statute retains the 260-week
maximum for injuries sustained within five years of the full-benefit eligibility, and the Court finds the offset
as defined in McCoy still applies. Here, the parties agreed Mr. Blank will be eligible for full Old Age
benefits at age sixty-six and one-half years, a date within five years of when he became eligible for
permanent disability payments.
                                                       7
IT IS, THEREFORE, ORDERED as follows:
  1. Estes shall pay Mr. Blank benefits for a two-percent permanent partial disability to
     the body as a whole, equal to nine weeks of benefits, at the adjusted rate of $512.22
     per week, or $4,609.98. After offset of the temporary total disability of $2,875.92,
     the total award is $1,734.06. Counsel is entitled to a twenty percent attorney fee of
     the total award, and the Court will consider an award of discretionary costs upon
     proper motion.

  2. Estes shall provide Mr. Blank future medical benefits under Tennessee Code
     Annotated section 50-6-204(a)(1)(A) if related to the August 30, 2018 injury. Dr.
     Hutchison shall be the authorized physician.

  3. Mr. Blank’s claim against the Subsequent Injury Fund is dismissed with prejudice.

  4. Estes shall pay $150 costs to the Court Clerk within five business days after this
     order becomes final under Tennessee Compilation Rules and Regulations 0800-02-
     21-.06 (February, 2022).

  5. Estes shall prepare and submit to the Court Clerk a Statistical Data Form (SD2)
     within ten business days of this order becoming final.

  6. Unless appealed, this order shall become final thirty days after issuance.

ENTERED March 22, 2022.

                                        ______________________________________
                                        JUDGE ALLEN PHILLIPS
                                        Court of Workers’ Compensation Claims

                                           8
                                      APPENDIX

Exhibits:
    1. Deposition of Dr. Samuel Chung
    2. Deposition of Dr. Adam Smith
    3. Deposition of Dr. Jason Hutchison
    4. Medical Records of Dr. Chung and West Tennessee Bone & Joint Clinic
    5. Copy of Mr. Blank’s prior settlement
    6. Documentation of temporary total disability repayment
    7. Still photographs of surveillance performed on Mr. Blank
    8. Documentation of Social Security payments (late filed)
    9. Pages from Mr. Blank’s deposition
    10. Mr. Blank’s agreement to repay temporary disability benefits

Technical record:
   1. Petition for Benefit Determination
   2. Dispute Certification Notice
   3. Request for Scheduling Hearing
   4. Scheduling Order
   5. Motion to Consolidate
   6. Order of Consolidation
   7. Compensation Order Granting Summary Judgment
   8. Employee’s Pre-Hearing Statement
   9. Employee’s Witness and Exhibit List
   10. Employer’s Pre-Hearing Statement
   11. Employer’s Witness and Exhibit List
   12. Subsequent Injury Fund’s Pre-Hearing Statement
   13. Post-Discovery Dispute Certification Notice
   14. Subsequent Injury Fund Trial Brief
   15. Employer’s Trial Brief
   16. Order of Continuance
   17. Second Order of Continuance
   18. Order Resetting Compensation Hearing

                                        9
                          CERTIFICATE OF SERVICE

     I certify that a copy of this Order was sent as indicated on March 22, 2022.

                 Name                      Email    Service sent to:
Jeffrey P. Boyd,                            X       jboyd@borenandboyd.com
Employee’s Attorney                                 dmyles@borenandboyd.com
Kenneth Veit,                                  X    kenny.veit@leitnerfirm.com
Employer’s Attorney                                 crystal.brown@leitnerfirm.com
Art D. Wells, SIVRF Attorney                   X    art.wells@tn.gov

                                        _____________________________________
                                        Penny Shrum, Court Clerk
                                        Court of Workers’ Compensation Claims

                                          10
                         Compensation Hearing Order Right to Appeal:
     If you disagree with this Compensation Hearing Order, you may appeal to the Workers’
Compensation Appeals Board or the Tennessee Supreme Court. To appeal to the Workers’
Compensation Appeals Board, 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 thirty calendar days of the date the
      compensation hearing order was filed. When filing the Notice of Appeal, you must serve
      a copy upon the opposing party (or attorney, if represented).

   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 filing 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
      your 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. A licensed court
      reporter must prepare a transcript and file it with the court clerk within fifteen calendar
      days of the filing the Notice of Appeal. Alternatively, you may file a statement of the
      evidence prepared jointly by both parties within fifteen calendar 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 of
      the evidence 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. After the Workers’ Compensation Judge approves the record and the court clerk transmits
      it to the Appeals Board, a docketing notice will be sent to the parties. The appealing party
      has fifteen calendar days after the date of that notice to submit a brief to the Appeals Board.
      See the Practices and Procedures of the Workers’ Compensation Appeals Board.
To appeal your case directly to the Tennessee Supreme Court, the Compensation Hearing
Order must be final and you must comply with the Tennessee Rules of Appellate Procedure.
If neither party timely files an appeal with the Appeals Board, the trial court’s Order will
become final by operation of law thirty calendar days after entry. See Tenn. Code Ann. §
50-6-239(c)(7).

For self-represented litigants: Help from an Ombudsman is available at 800-332-2667.
                                                  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 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