Hopson, Michael v. Driven Brands Holdings

FILED
Nov 18, 2022
08:39 AM(CT)
TENNESSEE COURT OF
WORKERS' COMPENSATION
CLAIMS
TENNESSEE BUREAU OF WORKERS’ COMPENSATION
IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT NASHVILLE
Michael Hopson, ) Docket No. 2022-06-0393
Employee, )
v. )
Driven Brands Holdings, ) State File No. 69720-2021
Employer, )
And )
Hartford Accident and Indemnity Co., ) Judge Kenneth M. Switzer
Carrier. )
EXPEDITED HEARING ORDER
Michael Hopson injured multiple body parts in a car accident while working for
Driven Brands Holdings on August 18, 2021. Driven Brands accepted the claim,
authorized treatment with various physicians, and paid temporary total disability benefits
during periods when authorized doctors took him off work.
The parties now disagree regarding Mr. Hopson’s request for additional medical
benefits. Although Driven Brands agreed to pay for all authorized treatment, it disputes
Mr. Hopson’s entitlement to additional treatment and temporary disability benefits.
After an expedited hearing on November 2, 2022, the Court holds Mr. Hopson is
likely to prevail at a hearing on the merits on his entitlement to additional treatment with a
dentist and neurologist, and to past temporary total disability benefits from July 1 to 19,
2022.
Claim History
Treatment
The work accident caused injuries to Mr. Hopson’s head, neck, left shoulder, teeth
and eyesight. He testified that he went to the emergency room afterward but offered no
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records from that treatment. Mr. Hopson has received treatment from many authorized
physicians since then.
The authorized treatment began in September 2021, when Mr. Hopson chose Dr.
Malcolm Steele from a panel of physicians. He saw Dr. Steele’s physician assistant
throughout his initial treatment. At the first visit, she diagnosed a left-shoulder contusion,
neck strain, headache, broken tooth and visual floaters, and she ordered physical therapy.
She referred Mr. Hopson to Promise Dental for his teeth, and an ophthalmologist, Dr. Stuart
Shofner, for his vision. On October 19, the physician assistant released Mr. Hopson to full-
duty work.
In the meantime, Mr. Hopson saw Dr. Shofner in October. He noted , “[p]t has
cataracts, non-work-related,” and returned him to full-duty work. According to Mr.
Hopson, Dr. Shofner also prescribed polarized sunglasses, but he did not provide any
evidence relating the need for glasses to a work-related condition.
As to his teeth, Mr. Hopson was seen at Promise Dental on November 1. The dentist
recommended an extraction and bone graft. Promise Dental sent Mr. Hopson to another
dental practice to begin the treatment; according to Mr. Hopson, the dentist at Promise
Dental does not perform the required dentistry. An implant remains necessary. Mr.
Hopson testified that the dental work is incomplete because the provider (Promise Dental
or possibly the other dental practice) requested payment upfront.
Driven Brands argued that Mr. Hopson declined to sign a form agreeing to be liable
if the carrier did not pay the bill, but counsel did not introduce this form. According to
Driven Brands’s attorney, it asked to pre-pay, but Promise Dental did not agree. Driven
Brands also looked for other dental practices to complete treatment, but they likewise
require Mr. Hopson’s signature on “standard” co-liability paperwork. Counsel offered no
proof on these contentions. Driven Brands additionally asserted that some of the
recommended dental treatment is not work-related, but it offered no medical proof on that
point, and Mr. Hopson denied that any dentist told him that.
Mr. Hopson’s shoulder, neck, and head symptoms persisted about three months after
the accident, so he returned to Dr. Steele. The physician assistant referred him to a
neurologist. On December 3, she referred him to an orthopedic specialist for his neck and
shoulder and took him off work, noting he should not drive until seen by a specialist.
Mr. Hopson saw a panel-selected neurologist, Dr. Subir Prasad, on January 13,
2022. Dr. Prasad diagnosed a post-traumatic headache and a blind spot in his vision, and
he recommended an MRI.
In February 2022, Mr. Hopson saw orthopedist Dr. Ryan Snowden for his neck and
shoulder. Dr. Snowden concluded that the shoulder is “the source of his discomfort.” So,
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he referred him to a shoulder specialist, Dr. Matthew Willis. Driven Brands honored the
referral.
Mr. Hopson saw Dr. Willis once, on March 3. Dr. Willis diagnosed adhesive
capsulitis, recommended additional physical therapy, and administered an injection. Dr.
Willis also noted that he believed modified duty was appropriate, but he declined to see
Mr. Hopson again due to their disagreement over whether he should be off work entirely.
Other than more physical therapy, treatment for the shoulder did not resume for several
months.
Returning to the neurological treatment, Mr. Hopson had an MRI in late March. At
the next visit on June 1, Dr. Prasad prescribed headache medication, took Mr. Hopson off
work, and restricted him from driving. Dr. Prasad recommended a return visit in the next
month.
Mr. Hopson testified that when he tried to follow up with Dr. Prasad in late June
and early July, he arrived at appointments but was turned away because he did not pass the
clinic’s Covid-19 protocols. He likewise testified that he attended physical therapy, but
had to stop in July due to illness.
Then in a July 19 letter, Dr. Prasad released Mr. Hopson to full-duty work. The
next day, Dr. Prasad wrote another letter discharging him from his care but also wrote that
Mr. Hopson should see another physician. Neither party introduced notes from any visit
with Dr. Prasad in July; it is unknown whether he saw Dr. Prasad at that time. Mr.
Hopson’s declaration states that he is still experiencing headaches and other symptoms.1
Returning to the shoulder, Mr. Hopson testified on cross-examination that he
selected specialist Dr. Chad Price from a panel. Dr. Price saw him on September 22 and
found chronic shoulder pain. He explained:
His exam is consistent with a possible cervical spine pathology or rotator cuff
tear. However, his mechanism of injury is not consistent with these
pathologies. He describes being hit from the side at approximately 15 mph.
That is not a mechanism consistent with a rotator cuff tear or cervical
pathology.
Dr. Price additionally recommended an MRI but wrote “we will decline the option to
pursue his treatment at this time.”
1
Mr. Hopson went to the emergency room on July 20, complaining of side effects from medications Dr.
Prasad prescribed and of Covid-19 symptoms. Records from that visit do not relate his condition to work
or to medications for the work injury; rather, they focus almost entirely on Covid-19.
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Medical Bills
Mr. Hopson introduced medical bills and explanation of benefit forms. Driven
Brands’s counsel reviewed them and stated that he believed bills for treatment with
authorized physicians had all been paid, or would be paid shortly. Counsel reviewed the
bills and agreed that Driven Brands has paid or will pay the following:
Physician Date of Service Amount
Dr. Prasad January 13, 2022 $315.00
June 1, 2022 $255.00
Promise Dental October 4, 2021 $365.00
November 1, 2021 $942.00
Periodontal and Implant November 22, 2021 $266.00
Association of Middle Tennessee
Driven Brands also agreed to pay for emergency treatment in 2021 for the work accident
but needs to investigate those sums further.
Temporary Disability Benefits
Mr. Hopson started receiving temporary benefits on August 27, 2021. Around that
same time, he received a separation letter, which he did not introduce. Mr. Hopson testified
that he was fired for filing a workers’ compensation claim but offered no proof of that. The
only other related evidence is a December 3, 2021 notice of controversy, which states that
Driven Brands stopped compensation, in part, because “[t]he claimant has been terminated
by his employer for cause[.]”
Mr. Hopson further testified that Driven Brands did not pay certain temporary
disability payments he believes he was owed throughout his treatment. Driven Brands
agreed that it did not pay at various times when Mr. Hopson was not under restrictions or
was noncompliant with treatment.
Mr. Hopson agreed on cross-examination that Dr. Steele’s physician assistant
returned him to full duty on October 19 and that afterward, neither Dr. Shofner nor Promise
Dental assigned work restrictions.2 The physician assistant took him off work again on
December 3, and Driven Brands reinstated temporary disability payments afterward. The
benefits ceased again in mid-March 2022, after Dr. Willis placed him on modified duty.
2
Mr. Hopson testified that Dr. Anna Skelo, an unauthorized provider, took him off work for this time in
response to counsel’s questioning on cross-examination, but he offered no medical records to prove that.
4
Benefits resumed on June 1, when Dr. Prasad took Mr. Hopson off work, but they
ended on July 1. A Notice of Change or Termination of Compensation Benefits dated June
30, 2022, states “Claimant has not complied with medical treatment as recommended by
the treating physician and there is no additional OOW information to support ongoing
payments.” Driven Brands has paid no disability benefits since.
Much of the testimony on cross-examination focused on Mr. Hopson’s alleged
noncompliance in June and July. Mr. Hopson testified that he had appointments with Dr.
Prasad on June 18 and July 11. He recalled that at least twice, he was turned away because
he could not pass the Covid-19 screening.
Along these lines, in June, Mr. Hopson resumed physical therapy but only
completed three sessions. Afterward, he said he felt too ill to attend, either because he may
have had Covid-19 or was experiencing side effects from medications. Mr. Hopson
maintained that he called and emailed to cancel the physical therapy appointments, which
had been set weeks in advance. He denied being rude or using foul language with staff.
Mr. Hopson tested positive for Covid-19 on July 20, as confirmed in emergency
room records from that date.
Findings of Fact and Conclusions of Law
For the Court to grant Mr. Hopson’s requests, he must show he is likely to prevail
at a hearing on the merits. Tenn. Code Ann. § 50-6-239(d)(1) (2022); McCord v.
Advantage Human Resourcing, 2015 TN Wrk. Comp. App. Bd. LEXIS 6, at *7-8, 9 (Mar.
27, 2015).
Additional Treatment
Driven Brands did not contest the compensability of Mr. Hopson’s claim but
contended that he is not entitled to more treatment, with the exception of finalizing the
dental work.
The Workers’ Compensation Law requires an employer to provide reasonable,
necessary treatment at no cost to the injured worker. Tenn. Code Ann. § 50-6-
204(a)(1)(A). Treatment is required only for conditions arising primarily out of
employment. Tenn. Code Ann. § 50-6-102(12). “Arising primarily out of employment”
means that it must be shown “to a reasonable degree of medical certainty” that the work
accident contributed more than fifty percent in causing the need for treatment.” Id.Considering each individual injury, Dr. Shofner wrote that Mr. Hopson’s cataracts
are not related to the work incident. Mr. Hopson offered no contrary medical proof. He
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cannot prevail on his request for more vision treatment without a medical opinion relating
his current eyesight problems to the work injury.
Likewise, Dr. Price concluded that Mr. Hopson’s shoulder injury did not arise from
employment, reasoning that the mechanism of injury could not have caused Mr. Hopson’s
current shoulder and neck conditions. Mr. Hopson did not introduce a conflicting medical
opinion to support the work-relatedness of these conditions. Moreover, Dr. Price’s opinion
is presumed correct under Tennessee Code Annotated section 50-6-102(12)(E).
The remaining, more difficult questions involve treatment for his teeth and
headaches.
Turning first to the dental treatment, Mr. Hopson testified, without contradiction,
that the authorized provider required pre-payment. Driven Brands offered explanations
from its attorney regarding why this treatment is at a standstill. But it offered no actual
evidence, such as a copy of the disputed “standard” form requiring Mr. Hopson to pay if
the carrier does not pay, or an affidavit from its adjuster explaining the difficulties she
encountered in authorizing the treatment.
Given the past delays in payment for authorized treatment, Mr. Hopson’s reluctance
to agree to be liable if the carrier declines payment is entirely reasonable—especially since
Driven Brands alleged, without an expert opinion, that some of the treatment is not work-
related. Further, no admissible proof suggests that Promise Dental is unwilling to accept
pre-payment, and the Court cannot imagine why that would be unacceptable to any
physician.
Section 50-6-204(a)(1)(A) is clear: treatment should be “free of charge . . . including
such dental work made reasonably necessary by accident[.]” Driven Brands must abide by
this charge. The Court holds that Mr. Hopson is likely to prevail at a hearing on the merits
that he is entitled to additional dental treatment. If Promise Dental refuses to treat Mr.
Hopson further, Driven Brands must continue to offer panels of dentists until a dentist
willing to treat him is located.
The next question is whether Mr. Hopson is entitled to additional neurological
treatment for his headaches. While Driven Brands pointed to a note placing him at full
duty, no medical record suggests that Mr. Hopson saw Dr. Prasad for the recommended
follow-up visit to determine whether he needs additional treatment. Instead, the parties
offered two letters: on July 19, Dr. Prasad wrote that he may return to work without
restrictions, and on July 20, the doctor wrote that he “cannot serve as [Mr. Hopson’s]
physician,” but he did not give any reason for the discharge. He also wrote that Mr. Hopson
“should place [him]self under the care of another physician as soon as possible.”
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The Appeals Board wrote in Limberakis v. Pro-Tech Sec., Inc., 2017 TN Wrk.
Comp. App. Bd. LEXIS 53 (Sept. 12, 2017), that “an employer cannot unilaterally
terminate an employee’s entitlement to reasonable and necessary medical benefits
following a compensable work injury.” Id. at *6.
In Limberakis, the authorized treating physician placed the employee at maximum
medical improvement, determined he needed no additional treatment, and refused to see
him. After an expedited hearing, the Court ordered the employer to offer a panel, and the
Appeals Board affirmed. The Board wrote, “In the absence of evidence directed
specifically to the issue of termination of treatment, the employer must provide [the
employee with] future, free reasonably necessary medical treatment.” Id. The Board found
it “significant” and “determinative” that the case was at the interlocutory phase and that
the employee’s claim was accepted. Id. at *9.
Here, no evidence suggested that Mr. Hopson is at maximum medical improvement
or that he does not need additional treatment for his headaches. In fact, Dr. Prasad
recommended that he find another doctor. Mr. Hopson testified in his declaration that he
still suffers symptoms. An employee’s assessment as to his own physical condition “is
competent testimony that is not to be disregarded.” Id. at *10.
As for the asserted noncompliance, Tennessee Code Annotated section 50-6-
204(d)(7) states that when an employee “refuses . . . to accept the medical . . . services that
the employer is required to furnish . . ., the injured employee’s right to compensation shall
be suspended and no compensation shall be due and payable while the injured employee
continues to refuse.” The Appeals Board explained that this provision means that “in
circumstances where an employee is noncompliant with medical treatment, compensation
shall be held in abeyance, not terminated.” Newell v. Metro Carpets, LLC, 2016 TN Wrk.
Comp. App. Bd. LEXIS 57, at *4-5 (Sept. 28, 2016).
In this case, even after rigorous cross-examination, Driven Brands offered no
evidence that Mr. Hopson “refused” to accept Dr. Prasad’s treatment. Mr. Hopson
testified, without contradiction, that he went to the clinic twice but was turned away due to
Covid-19 symptoms. He also stated that feeling ill, possibly from Covid-19 or side effects
from medication, prevented him from completing physical therapy. The Court finds no
“refusal” under these circumstances. Notably, Driven Brands terminated compensation on
July 1, before any missed July appointments with either Dr. Prasad or physical therapy.
The noncompliance argument is unpersuasive.
Therefore, Mr. Hopson is likely to prevail at trial on his request for additional
treatment from a neurologist. Since Dr. Prasad refuses to treat Mr. Hopson, Driven Brands
must offer a panel of neurologists. Limberakis, at *10.
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Medical Bills
Driven Brands agreed that it is responsible for authorized treatment as outlined
previously. It shall investigate whether bills for any work- related post-accident emergency
treatment are outstanding, and if so, pay them immediately. On this record, however, the
Court cannot order payment for the remaining sums. Mr. Hopson may gather additional
evidence showing that the bills were for reasonable and necessary treatment, which was
causally-related to the work accident. Eaves v. Ametek, Inc., 2018 TN Wrk. Comp. App.
Bd. LEXIS 53, at *8 (Sept. 14, 2018).
Temporary Disability Benefits
The workers’ compensation statutes list two types of temporary disability benefits:
temporary partial disability benefits and temporary total disability benefits. See Tenn.
Code Ann. § 50-6-207.
First considering temporary partial disability benefits, as applicable here, these are
warranted when a treating physician has released the injured worker to return to work with
restrictions before maximum medical improvement, and the employer cannot return the
employee to work within the restrictions. Jones v. Crencor Leasing and Sales, 2015 TN
Wrk. Comp. App. Bd. 48, at *8 (Dec. 11, 2015). However, an employee who is terminated
for cause is not entitled to temporary partial disability benefits. Id. at *10.
Here, the evidence is inconclusive. Mr. Hopson testified that he was terminated
because he filed a workers’ compensation claim, but he offered no supporting
documentation. In contrast, Driven Brands relied on a form stating the termination was for
cause, but it did not provide supporting documentation or testimony.
Mr. Hopson bears the burden of proof. Tenn. Code Ann. § 50-6-239(c)(6). At this
time, he has not satisfied his burden as to temporary partial disability benefits. Based on
this record, for the periods where Mr. Hopson was placed on restricted duty, the evidence
is insufficient to show either that Driven Brands could not return him to work within the
restrictions, or that it fired him without cause. Mr. Hopson may gather additional evidence
and renew his request for these benefits at a later hearing.
Turning now to temporary total disability benefits, an injured worker is eligible for
them if: (1) the worker became disabled from working due to a compensable injury; (2)
there is a causal connection between the injury and the inability to work; and (3) the worker
established the duration of the period of disability. Jones, at *7. Temporary total disability
benefits are terminated by the ability to return to work. Id.Applying these principles, Driven Brands accepted the claim with regard to the head
8
injury, so a causal connection exists between the injury and Mr. Hopson’s inability to work
or drive.
As to the duration of disability, Dr. Prasad’s records clearly state that he was off
work starting June 1, 2022. As previously discussed, Mr. Hopson complied with treatment.
Still, Driven Brands ended compensation on July 1, before Dr. Prasad returned him to full
duty on July 19. Therefore, Mr. Hopson has shown total disability from July 1 through
July 19, or nineteen days. The Court holds Mr. Hopson is likely to prevail at trial in proving
entitlement to temporary total disability benefits for this period.
As a final matter, Mr. Hopson is not currently restricted from work by any
authorized physician, so he is not entitled to ongoing temporary disability benefits at this
time.
IT IS THEREFORE ORDERED AS FOLLOWS:
1. Driven Brands must authorize and schedule, within ten business days of this order,
additional treatment with Promise Dental for any reasonable and necessary dental
treatment causally-related to the work injury under Tennessee Code Annotated
section 50-6-204(a)(1)(A). If Promise Dental is unwilling to continue to treat Mr.
Hopson, within ten business days of this order, Driven Brands must offer him a
panel of dentists willing to treat him and shall immediately schedule an appointment
once Mr. Hopson makes his selection. Driven Brands must continue to offer Mr.
Hopson a panel of dentists until a willing dentist is located.
2. Driven Brands must offer a panel of neurologists within ten business days of this
order, for Mr. Hopson to select another physician for any reasonable and necessary
medical treatment causally-related to the work injury under Tennessee Code
Annotated section 50-6-204(a)(1)(A). Driven Brands shall immediately schedule
an appointment once Mr. Hopson makes his selection.
3. Driven Brands must pay, within ten business days of this order, for all past
authorized medical treatment. It shall also investigate whether any sums are owed
for post-accident emergency treatment., and if so, it shall pay them immediately. It
must also continue to promptly pay for all continuing authorized medical treatment
that is reasonable, necessary and related to the work accident.
4. Driven Brands must pay Mr. Hopson, within ten business days of this order, past
temporary total disability benefits totaling $2,331.49.3 No other disability benefits
are currently owed.
3
Mr. Hopson’s agreed weekly compensation rate is $858.98, or a daily rate of $122.71. When multiplied
by nineteen days, he is owed $2,331.49.
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5. The Court sets a status hearing on January 30, 2023, at 9:45 a.m. Central Time.
You must dial (615) 532-9552 or (866) 943-0025 to participate.
6. 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
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.
ENTERED November 18, 2022.
________________________________________
JUDGE KENNETH M. SWITZER
Court of Workers’ Compensation Claims
10
Appendix
Technical record:
1. Petition for Benefit Determination
2. Dispute Certification Notice
3. Order Setting Status Hearing
4. Request for Expedited Hearing
5. Order on Status Hearing
6. Employee’s Unpaid Temporary Disability Benefits
7. Unfinished Dental Treatment/Unpaid Temporary Disability Benefits (amended)
Evidence:
1. Declaration of Mr. Hopson
2. Composite Medical Records
3. Wage statement
4. Panels
5. Notices of Controversy
6. Medical bills/explanation of benefit forms
7. (None)
8. Dental treatment records (identification only)
9. Works restrictions
10. Records, Dr. Chad Price
11. Records, Ascension St. Thomas Hospital West
CERTIFICATE OF SERVICE
I certify that a copy of this Order was sent as indicated on November 17, 2022.
Name Certified Regular Email Sent to
Mail mail
Michael Hopson, X X mhopson@comcast.net
employee 3121 Wilmoth Rd.
Nashville TN 37207
Joseph Ballard, X Joseph.ballard@thehartford.com
employer’s attorney
_______________________________________
Penny Shrum
Clerk, Court of Workers’ Compensation Claims
WC.CourtClerk@tn.gov
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Expedited Hearing Order Right to Appeal:
If you disagree with this Expedited Hearing Order, you may appeal to the Workers’
Compensation Appeals Board. To appeal an expedited hearing order, you must:
1. Complete the enclosed form entitled: “Notice of Appeal,” and file the form with the
Clerk of the Court of Workers’ Compensation Claims within seven business days of the
date the expedited hearing order was filed. When filing the Notice of Appeal, you must
serve a copy upon all parties.
2. You must pay, via check, money order, or credit card, a $75.00 filing fee within ten
calendar days after filing of the Notice of Appeal. Payments can be made in-person at
any Bureau office or by U.S. mail, hand-delivery, or other delivery service. In the
alternative, you may file an Affidavit of Indigency (form available on the Bureau’s
website or any Bureau office) seeking a waiver of the fee. You must file the 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 Indigency will
result in dismissal of the appeal.
3. You bear the responsibility of ensuring a complete record on appeal. You may request
from the court clerk the audio recording of the hearing for a $25.00 fee. If a transcript of
the proceedings is to be filed, a licensed court reporter must prepare the transcript and file
it with the court clerk within ten business days of the filing the Notice of
Appeal. Alternatively, you may file a statement of the evidence prepared jointly by both
parties within ten business days of the filing of the Notice of Appeal. The statement of
the evidence must convey a complete and accurate account of the hearing. The Workers’
Compensation Judge must approve the statement before the record is submitted to the
Appeals Board. If the Appeals Board is called upon to review testimony or other proof
concerning factual matters, the absence of a transcript or statement of the evidence can be
a significant obstacle to meaningful appellate review.
4. If you wish to file a position statement, you must file it with the court clerk within ten
business days after the deadline to file a transcript or statement of the evidence. The
party opposing the appeal may file a response with the court clerk within ten business
days after you file your position statement. All position statements should include: (1) a
statement summarizing the facts of the case from the evidence admitted during the
expedited hearing; (2) a statement summarizing the disposition of the case as a result of
the expedited hearing; (3) a statement of the issue(s) presented for review; and (4) an
argument, citing appropriate statutes, case law, or other authority.
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 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 *
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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