Hardin, Gregory v. W.A. Kendall & Co., Inc. ( 2019 )

FILED
Feb 13, 2019
01:08 PM(CT)
TENNESSEE COURT OF
WORKERS' COMPENSATION
CLAIMS
TENNESSEE BUREAU OF WORKERS' COMPENSATION
IN THE COURT OF WORKERS' COMPENSATION CLAIMS
AT GRAY
GREGORY HARDIN, ) Docket Number: 2017-02-0333
Employee, )
v. )
W.A. KENDALL & CO., INC., ) State File Number: 4528-2017
Employer, )
and )
XL INSURANCE AMERICA, ) Judge Brian K. Addington
Carrier. )
COMPENSATION HEARING ORDER
This case came before the Court January 24-28, 2019, for a compensation hearing.
The legal issues are whether Mr. Hardin's claim is barred by willful misconduct, and if
not, the amount of benefits due. The Court holds that Mr. Hardin suffered a compensable
injury that was not barred by willful misconduct. As explained below, it awards him past
and future lifetime medical benefits, temporary total and permanent partial disability
benefits, and reasonable attorney's fees.
History of Claim
W.A. Kendall hired Mr. Hardin in January 2016 to work as a groundsman on its
wood clearing crew. 1 It provided him with a handbook and laborer training manual, and
he passed a test associated with the training manual. Later, he received on-the-job
training to operate a wood chipper from his foreman, Dusty Shaffer, who instructed him
to approach a chipper from the rear in an arc, use both hands to throw the material into
the chipper, and continue in the arc while moving away to pick up another pile. These
instructions mirrored the instructions in W .A. Kendall's handbook. 2
A couple of months later, Mr. Hardin and other employees received a written
record of instruction on March 16, 2016, for feeding the chipper from behind instead of
1
Mr. Hardin's average weekly wage was $434.89, which provides a $289.93 compensation rate.
2
The materials reflect that W.A. Kendall's policies were more guidelines than inflexible rules.
1
from the side. The chipper also had stickers that warned operators to follow instructions
in the operator's manual, always or constantly to remain in position to operate the control
bar to stop the machine if necessary, and to never push items too far into the chipper.
On the day of the accident, January 18, 2017, Mr. Hardin and groundsman
Brandon Moore were the only employees at the Wiseman worksite. Mr. Moore operated
a leaf blower, while Mr. Hardin chipped brush. Mr. Hardin testified at trial that he picked
up a bundle of brush, walked toward the chipper in an arc pattern, and fed it into the
chipper. At that time, a vine entangled his right arm. He grabbed his right arm with his
left in an attempt to draw back his right arm. The power of the machine caused him to
lose his footing and fall face first onto the feed table. As the chipper started to pull his
right hand into the rollers, he turned to his back and struck the control bar with his legs,
stopping the chipper. He extracted himself from the machine, but the chipper severed his
right hand, and he suffered partial amputation of his ear and significant facial lacerations.
Even though he did not witness the accident, Mr. Moore called 911. EMS
responder Robert Wells conducted a scene survey while others attended Mr. Hardin.
While assessing the scene, he backed away from Mr. Hardin and the chipper. In doing
so, he tripped over a brush pile, which was located to the rear of the chipper and near the
end of the gravel road leading to the upper reaches of the property. He testified he
remembered the brush pile because tripping over it embarrassed him.
EMS transported Mr. Hardin to the hospital where he was hospitalized for five
days. W. A. Kendall representatives visited him, but he was anesthetized and unable to
provide any statement.
Dr. Benjamin Knox operated on Mr. Hardin and concluded his hand could not be
saved. He referred Mr. Hardin to a prosthetist. Dr. Jim Brantner operated on his facial
and ear lacerations. Upon release, the hospitalist, Dr. Melissa Powell, restricted Mr.
Hardin's use of his right arm until an orthopedist cleared him. The hospital bills totaled
$72,482.
After the hospital released him, Mr. Hardin continued to treat with Dr. Brantner,
who never placed Mr. Hardin at maximum medical improvement (MMI) but did assign
ten percent whole-body impairment for his facial injuries. Mr. Hardin received treatment
for his hand injury from Dr. Kent Lord, who placed him at MMI on October 10, 2018,
and assigned sixty percent whole-body impairment for injuries to his right arm. Dr. Lord
noted Mr. Hardin was a good candidate for prosthesis and felt his permanent restrictions
depended on the prosthesis he received.
Mr. Hardin went to Bristol Orthotics and Prosthetics for a prosthesis evaluation.
There, Prosthetist and Orthotist Will Graybeal determined Mr. Hardin was a good
prosthesis candidate and recommended three different orthotic hands, a body powered
2
arm, a body powered recreational arm, and a myo-electric !-limb arm. Together, they
would enable him to do more complex activities, including up to ninety-five percent of
the activities he previously performed. Neither Dr. Knox nor Dr. Lord reviewed Mr.
Graybeal's recommendations.
W. A. Kendall did not speak with Mr. Hardin before it decided to deny his claim
on January 27, and it refused to pay his medical bills or pay temporary disability benefits.
On January 31, Mr. Hardin's attorney notified W.A. Kendall of his representation and
requested a Panel of Physicians. W.A. Kendall formally filed a Notice of Denial on
February 28 alleging Mr. Hardin was guilty of misconduct and had failed to follow a
safety rule. It never provided a panel of physicians.
Mr. Hardin hired Charles Coones, a Certified Safety Professional, as an expert to
recreate the chipping accident. Based on Mr. Hardin's account, Mr. Coones recreated the
event using a similar machine and a fireman dummy. Mr. Coones concluded it was
highly probable the chipper pulled him in as Mr. Hardin testified at trial.
W. A. Kendall hired Dr. Richard Ziernicki as its expert. 3 He relied on Mr.
Hardin's deposition testimony as to where he was standing when the incident occurred,
Mr. Moore's placement of the chipper, and circumstantial evidence from the scene. He
concluded Mr. Hardin was not standing where he indicated but was to the rear of the
chipper. He determined if Mr. Hardin was standing as he testified in his deposition, his
body would have hit the control bar, and if he was not there, he violated W. A. Kendall's
safety rules. He assumed that Mr. Hardin tried to flick materials that were in the hopper
in violation of the rules. 4
Findings of Fact and Conclusions of Law
Mr. Hardin must prove all elements of his case by a preponderance of the
evidence. Tenn. Code Ann. § 50-6-239(c)(6) (2018).
As the threshold issue, Mr. Hardin must prove the compensability of his claim.
Specifically, he must show he suffered "an injury by accident ... arising primarily out of
and in the course and scope of employment." Tenn. Code Ann. § 50-6-102(14). If he
establishes an injury, then Tennessee Code Annotated section 50-6-204(a)(l)(A) requires
"[t]he employer or the employer's agent [to] furnish, free of charge to the employee, such
medical ... treatment ... made reasonably necessary by accident[.]"
3
Both experts were well qualified to testify on the matter.
4
He came to this conclusion based on statements from employees that all the brush had already been cut,
and that Mr. Hardin was just throwing rakings into the chipper.
3
Mr. Hardin suffered open and obvious injuries to his right hand, face and ear when
the wood chipper pulled him in while working for W. A. Kendall. The Court holds by a
preponderance of the evidence that he suffered an injury arising primarily out of and in
the course and scope of his employment.
The Court must consider, however, whether Mr. Hardin's compensable injury was
barred by willful misconduct. Tenn. Code Ann. § 50-6-llO(a)(l). W.A. Kendall has the
burden to prove such defense. Tenn. Code Ann. § 50-6-110(b). It must prove Mr.
Hardin violated a work rule; he had actual, as opposed to constructive notice of the rule;
he understood the danger involved in violating the rule; the bona fide enforcement of the
rule by W. A. Kendall; and, the lack of a valid excuse for violating the rule. Mitchell v.
Fayetteville Pub, Utils., 368 S.W.3d 442, 453 (Tenn. 2012).
W. A. Kendall asserted that Mr. Hardin violated three rules: 1) he did not feed the
wood chipper from the ditch side; 2) he reached his hand into the hopper; and 3) he was
not in a position to control the safety bar as he operated the chipper. The Court will
analyze each alleged rule violation using the elements set out in Mitchell.
Concerning the first rule, W.A. Kendall proved by a preponderance of the
evidence that Mr. Hardin had notice. Its handbook and the operation manual stated the
correct way to feed a chipper is by approaching it from the rear on the ditch side. Mr.
Hardin testified he was aware of the danger in violating the rule and had been written up
for violating it once, although he denied actually violating it. But he also testified that at
the time of the accident, he was feeding the machine from the rear ditch side.
W.A. Kendall's expert concluded that if Mr. Hardin had been standing center mass
on the ditch side of the feed table, his body would have engaged the safety bar as the
chipper pulled him into the machine. He compared this to a fish on a taut line. However,
the Court finds Mr. Hardin to be credible when he testified that he fought to free himself
by grabbing his right arm with his left dominant arm. This would have changed his
position and would not have prevented him from moving side to side or up and down as
the machine pulled him in. Dr. Ziemicki's reenactment does not allow for such a
scenario, only exhibiting a static dummy being pulled into the machine.
Dr. Ziernicki relied on Mr. Hardin's deposition testimony wherein he made an ink
slash on a diagram that purportedly showed him "standing" in the middle of the feed
table on the chipper's ditch side when he threw brush into it. In Dr. Ziemicki's
reenactment, he positioned a man standing in the center of the ditch side of the feed table.
However, the evidence does not support such positioning. Mr. Hardin testified and
demonstrated that he was not "standing" anywhere but was walking as he fed the
machine. Also, the mark on the chipper diagram is not proportional to the size of a
human body when standing next to the machine. If it were, Mr. Hardin would be
represented by a thin ink slash. Mr. Hardin did not intend to make a mark to indicate his
body covered the width ofthe ditch side of the feed table.
4
W.A. Kendall's training manual and videos show an employee correctly
approaching the chipper from the rear on the ditch side. Mr. Hardin testified he did the
same on the date ofinjury. 5
Even if W.A. Kendall proved Mr. Hardin violated the rule, it failed to prove he did
not have a valid excuse for doing so. The Court finds that on the day of the accident, Mr.
Hardin fed the chipper as he was trained by his superiors, so if he violated the rule, W. A.
Kendall failed to prove he lacked a valid excuse for doing so.
Concerning rule two, Dr. Ziernicki concluded that Mr. Hardin could not have been
at the side of the feed table but was behind it reaching into the hopper, which was a
violation of the rule. He came to this conclusion based on statements from Mr. Moore
and others that there were no big items to throw into the chipper but just small rakings.
He then assumed that the small clippings could have not made it to the rollers, and Mr.
Hardin reached into the hopper to flick them into the rollers.
There was conflicting testimony on the pile of branches, as some employees did
not see a large pile of branches after the accident. However, Mr. Wells testified as did
Mr. Hardin that there was large brush still to be chipped at the scene. Mr. Wells
recounted his embarrassment from falling in the pile. The Court finds his testimony
highly credible. The preponderance of the evidence does not support W. A. Kendall's
assertion that Mr. Hardin reached into the hopper because there were only small clippings
left to be chipped.
As to the notice about the safety bar, the Court does not consider it a rule, but a
warning. Nonetheless, every person who described operating the chipper or
demonstrated its use for a video illustrated using both hands to throw brush into the
chipper. It would be anatomically impossible to grab the control bar at all times during
the feeding/chipping process. Therefore, even if it were a rule, Mr. Hardin had a valid
excuse for violating it.
Because the Court holds that Mr. Hardin suffered a compensable injury, he is
entitled to necessary and reasonable medical benefits. He proved his work-r lated injm
was primarily responsible for his need for medical treatment. 6 Thus, the CoUJt holds
W.A. Kendall shall pay for all emergency treatment that Mr. Hardin received at the
hospital in the amount of $72,482.
5
The Court notes a slight discrepancy between Mr. Hardin's trial testimony and his deposition testimony,
but the Court finds it inconsequential. Mr. Hardin repeated at trial on direct and cross as to what
happened on the date of the injury. The Court notes he did not waiver in his testimony at trial.
6
This information is contained in the C-32s from Drs. Lord and Brantner.
5
Mr. Hardin requested a panel of physicians for his compensable injury on January
31, 2017, which W. A. Kendall denied. The Court holds Mr. Hardin was reasonable in
seeking treatment with Drs. Knox, Lord, and Brantner. W.A. Kendall shall pay for Mr.
Hardin's prior treatment and ongoing medical treatment with these physicians that is
related to his injury. As to Mr. Hardin's request for approval of Mr. Graybeal's
prosthetic arm recommendations, the Court holds this issue is best left to physicians. Mr.
Hardin must return to Dr. Knox or Dr. Lord for a determination of the prosthetic devices
that are reasonable and necessary for his injury. 7
Concerning temporary total disability benefits, Mr. Hardin must prove by a
preponderance of the evidence: (1) a 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 Canst. Co., Inc., 2016
TN Wrk. Comp. App. Bd. LEXIS 15, at *13 (Mar. 30, 2016). Dr. Melissa Powell
restricted Mr. Hardin's use of his right arm until he was cleared by an orthopedist. Dr.
Lord found that Mr. Hardin's injury had caused him to miss work and did not place him
at MMI until October 8, 2018. Thus, Mr. Hardin proved entitlement to temporary total
disability benefits of $26,010.87. 8
Regarding permanent partial disability benefits, an employee who establishes a
partial disability from a compensable permanent injury is entitled to payment of
permanent partial disability benefits for the number of weeks calculated by multiplying
the applicable impairment rating by 450 weeks. Tenn. Code Ann. § 50-6-207(3)(A).
These benefits are paid at the weekly compensation rate whether or not the employee
returns to work. !d. The Workers' Compensation Law refers to this as the original
award. Dr. Lord assigned a sixty percent impairment rating to the whole body. 9
Therefore, the Court finds he sustained a sixty percent permanent partial impairment.
This equates to an original award of 270 weeks benefits or $78,281.10.
Finally, Mr. Hardin requested attorney fees for W.A. Kendall's wrongful denial of
his claim. The Court holds Mr. Hardin is entitled to the requested fees.
Tennessee Code Annotated section 50-6-226( d)(l )(B) allows the Court to award
reasonable attorney's fees and costs when an employer wrongfully denies a claim or fails
7
Dr. Lord referred Mr. Hardin for a prosthetic-orthotic evaluation, and the Court found Prosthetist
Graybeal qualified to testifY as an expert at trial. However, the specific types of prosthetics recommended
were not ordered by Dr. Lord or Dr. Knox.
8
This amount represents eighty-nine weeks and five days, as 20 16 was a leap year.
9
Although Dr. Brantner's impairment rating was entered as exhibit twenty-four, Dr. Brantner never
placed Mr. Hardin at MMI, and Mr. Hardin did not request permanent disability payments based on Dr.
Brantner's rating in his pre-hearing statement or at trial.
6
to timely initiate benefits. At the time of Mr. Hardin's injury, the statute did not define
the term "wrongfully." However, in a 2018 amendment, the Legislature defined
"wrongfully" to mean "erroneous, incorrect, or otherwise inconsistent with the law or
facts." In Andrews v. Yates Serv., LLC, 2018 TN Wrk. Comp. App. Bd. LEXIS 22 (May
8, 20 18), the Appeals Board held that, although the amended definition does not directly
apply to injuries prior to its enactment, like Mr. Hardin's injury, a court should "look to
the new statute as persuasive authority in evincing the General Assembly's original
intent." /d. at *9.
In Andrews, the Board concluded that:
a trial court may consider whether an employer's decision to deny a claim was
erroneous, incorrect, or otherwise inconsistent with the law or facts at the time the
denial decision was made. Thus, it is within a trial court's discretion to consider
an employer's decision to deny a claim in light of evidence or other information
reasonably available to the employer at the time the claim was denied.
/d. at *12 (Emphasis added).
Applying that authority here, the Court holds W. A. Kendall's actions at the time it
denied Mr. Hardin's claim were erroneous, incorrect, and inconsistent with the facts.
Namely W.A. Kendall did not speak with Mr. Hardin before its denial, relied upon only
circumstantial evidence, 10 and had no expe1i proof at that time which establjshed Mr.
Hardin's alleged misconduct. The investigation undertaken by W.A. Kendall "at the time
the denial decision was made" was inadequate to establish its willful misconduct defense
and, thus, was inconsistent with a complete picture of the facts as of the date of denial.
Therefore, the Court holds that Mr. Hardin should be awarded attorney fees. Mr.
Hardin's attorney shall submit an accounting of his time and hourly rate with an affidavit
for consideration of attorney fees. He shall also simultaneously submit a request for
reasonable and necessary costs. W.A. Kendall shall have five business days to respond.
IT IS, THEREFORE, ORDERED as follows:
1. The Court designates Drs. Knox, Lord, and Brantner as Mr. Hardin's authorized
physician. Mr. Hardin is awarded a judgment of $72,482 against W.A. Kendall
for past medical expenses, and W. A. Kendall shall provide reasonable and
necessary future medical treatment under Tennessee Code Annotated section 50-6-
204(a)(l)(A).
2. Mr. Hardin is awarded a judgment of $26,010.87 against W.A. Kendall for past
temporary total disability benefits.
10
Mr. Hardin was the only eyewitness to the accident.
7
3. Mr. Hardin is awarded a judgment of $78,281.10 against W. A. Kendall for
temporary total disability benefits. All incurred benefits shall be paid in lump sum
with the remaining in weekly benefits.
4. Mr. Hardin's attorney shall submit an accounting of his time and hourly rate with
an affidavit for consideration of attorney fees. He shall also simultaneously
submit a request for reasonable and necessary costs. W.A. Kendall shall have five
business days to respond.
5. W.A. Kendall shall pay $150.00 costs to the Court Clerk within five business days
under Tennessee Compilation Rules and Regulations 0800-02-21-.07.
6. W.A. Kendall shall prepare and submit a Statistical Data Form (SD2) within five
business days of this order becoming final.
7. W. A. Kendall failed to timely file a notice of denial or provide a panel to which
Mr. Hardin was entitled. The Court refers the case to the Bureau's Compliance
Unit for consideration of a penalty.
8. Absent an appeal, this order shall become final in thirty days after issuance.
ENTERED this the 13th day of February, 2019.
IS/ Brian K. Addington
BRIAN K. ADDINGTON, JUDGE
Court of Workers' Compensation Claims
APPENDIX
Exhibits:
1. Statement ofUnderstanding
2. Photo
3. Collective Exhibit-Photo (3)
4. Photo
5. Phot
6. Photo
7. Collective "' xhibit-Photos (4)
8. Employee s Choice of Physician Form
9. Photo
lO.Photo
8
11. Photo
12. Labor Training Manual
13. Test for Labor Training
14. Job Safety Analysis Form
15. Employee Handbook
16. Target Training Form
17. Collective Diagram (Deposition Exhibit 3)
18.Mentor Progress Sheet
19. MedicOne Medical Response
20. Johnson City Medical Center-Billing Statement
21. Photo
22. Johnson City Medical Center records
23. Standard Form Medical Report-Dr. Kent Lord
24. Standard Form Medical Report-Dr. Jim Brantner
25. Mortality Table
26. Prosthetist License of Will Graybeal
27. Orthotist License of Will Graybeal
28. Video-Limb Prosthetics
29. Recommended Prosthetic Hands Chart
30. Bristol Orthotics and Prosthetics records
31. Referral Order Dr. Benjamin Knox
32. Curriculum Vitae of Charles Coones
33. Forensic Investigations and Technologies preliminary report
34. Forensic Investigations and Technologies supplemental report
3 5. Demonstration video-Charles Coones
36. License Status Website (identification purposes)
3 7. Wage Statement
38.Notice ofDenial of Claim
39. TOSHA Report (identification purposes) 11
40. Video-Dr. Richard Ziernicki
41. Analysis of the Hazards of Wood Chipper Accidents
42. Video-W.A. Kendall demonstration video
43. Kendall Record of Instruction or Correction
44. Collective Exhibit-Photos (4 7)
45. New employee training video
46. Brandon Moore's Deposition
47. Brandon Moore's Affidavit
48. Affidavit of Criminal Complaint, Brandon Moore
49. Criminal Court Judgment, Brandon Moore
11
The Court reserved ruling on the admissibility of this document until it had an opportunity to review the
Appeals Board's decision in Kizer v. Express Servs. Inc., 2018 TN Wrk. Comp. App. Bd. LEXIS 17 (Apr.
20, 20 18). Based on the holding in Kizer, the Court finds W.A. Kendall did not lay a proper foundation
for this document.
9
50. Criminal Plea, Brandon Moore
51. Robert Williams' Deposition
52. Letter dated January 31, 2017
53.Email
54. Handwritten statements (identification purposes)
Technical Record:
1. Petition for Benefit Determination
2. Dispute Certification Notice
3. Employer's Motion to Compel HIPAA Release
4. Employee's Response to Motion to Compel HIPPA Release
5. Order Compelling Discovery
6. Employee's Notice of Compliance
7. Employee's Request for Scheduling Hearing
8. Scheduling Hearing Order
9. Employee's Motion for Permission to Serve Additional Interrogatories
10. Order Granting Additional Interrogatories
11. Employee's Motion to Amend Scheduling Order
12. Employer's Response to Motion to Amend
13. Order Granting Extension of Deadlines
14. Employer's Witness List
15. Employee's Witness List
16.Employee's Notice of Intent to Use C-32
17. Employer's Motion to File a Brief Exceeding Ten Pages
18.Employee's Motion in Limine
19.Employee's Motion to Exclude Discovery Depositions
20. Employee's Motion to Compel Expert Witness' Investigative File
21. Employee's Motion to File a Brief Exceeding Ten Pages
22. Post Discovery DCN
23. Employer's Response to Motion to Exclude Discovery Depostions
24. Employer's Response to Motion in Limine
25. Employee's Objection to Employer's Untimely Filing of Responses to Motions
26. Court Order on Motions
27. Employee's List of Proposed Exhibits
28. Employee's Pre-Compensation Hearing Statement
29. Employee's Pre-Compensation Hearing Brief
30. Employer's List of Proposed Exhibits
31. Employer's Pre-Compensation Hearing Statement
32. Employer's Notice of Filing Proposed Exhibits
33. Employer's Pre-Hearing Brief
10
13
II
I 'I
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: "Compensation Hearing 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 ofthe filing fee. You must file the fully-
completed 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 lndigency 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.
II I.
' I
Tennessee Bureau of Workers' Compensation
220 French Landing Drive, 1-B
Nashville, TN 37243-1002
800-332-2667
AFFIDAVIT OF INDIGENCY
I, , having been duly sworn according to law, make oath that
because of my poverty, I am unable to bear the costs of this appeal and request that the filing fee to appeal be
waived. The following facts support my poverty.
1. Full Name:_ _ _ _ __ _ _ _ _ __ 2. Address: - - - - - - - -- - - --
3. Telephone Number: - - - - - - - - - 4. Date of Birth: - - - - -- - - -- -
5. Names and Ages of All Dependents:
- - - - - - - - - - - - - - -- - Relationship: - - - - - - -- - - -- -
- - - - - - - - - - - - - -- -- Relationship: - - - - - -- - - -- - -
- - - - - - - - - - -- - -- - - Relationship: - - - -- - -- - - - - -
- - - - - - - - - - - - - - -- - Relationship: - - - - - - -- - - -- -
6. I am employed by: - - - - - - - - - - -- - - -- - - - - - -- - - -- - -
My employer's address is: - - - - -- - - - -- - - - - - -- - -- - - - -
My employer's phone number is: - - - -- - - - -- - - - - - -- - - -- - -
7. My present monthly household income, after federal income and social security taxes are deducted, is:
$ _ _ _ _ _ __
8. I receive or expect to receive money from the following sources:
AFDC $ per month beginning
SSI $ per month beginning
Retirement $ per month beginning
Disability $ per month beginning
Unemployment $ per month beginning
Worker's Camp.$ per month beginning
Other $ per month beginning
LB-1108 (REV 11/15) RDA 11082
9. My expenses are: ! ~ li
I
'
Rent/House Payment $ per month Med icai/Dental $ _ _ ___ per month
Groceries $ per month Telephone $ _ __ _ _ per month
Electricity $ per month School Supplies $ _ _ _ _ _ per month
Water $ per month Clothing $ _ _ _ _ _ per month
Gas $ per month Child Care $ _ _ _ _ _ per month
Transportation $ per month Child Support $ _ _ _ _ _ per month
Car $ per month
Other $ per month (describe:
10. Assets:
Automobile $ _ _ _ __
(FMV) - - - - - - - - - -
Checking/Savings Acct. $ _ _ _ __
House $ _ _ __
(FMV) - - - - - - - - - -
Other $ _ _ _ __ Describe:_ _ _ _ __ _ __ __
11. My debts are:
Amount Owed To Whom
I hereby declare under the penalty of perjury that the foregoing answers are true, correct, and complete
and that I am financially unable to pay the costs of this appeal.
APPELLANT
Sworn and subscribed before me, a notary public, this
____ dayof _____________________ , 20_ __
NOTARY PUBLIC
My Commission Expires:_ _ _ _ _ _ __
LB-1108 (REV 11/15) RDA 11082