Statistical Data Form {LB-0904}

S TATE F ILE # SOCIAL SECURITY NO : DATE OF INJURY : FORM SD1 LB-0904 (REV. -) RDA 10183 Revised 12 - 07 P age 1 of 3 pensation transacti on for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits. This area for Department use only. T HIS FORM MUST BE FIL ED WITH THE CLERK OF THE COURT CONTEMPORANEOUSLY WI TH THE FINAL ORDER I N ALL WORKERS COMPENSATION CASES I N WHICH THE COURT EITHER TRIES THE CAS E OR APPROVES A SETT LEMENT . F OR SETTLEMENTS SUBMITTE D TO THE D EPARTMENT OF L ABOR & W ORKFORCE D EVELOPMENT FOR APPRO VAL , SUBMIT THIS FORM WITH THE A PPROVAL REQUEST . N EITHER THE ORDER OF THE COURT N O R THE D EPARTMENT S APPROVAL IS FINAL UN TIL THIS FORM IS FUL LY COMPLETED AND FILED WITH THE APPROPRIATE ENTITY . [S TATUTORY A UTHORITY : TCA 50 - 6 - 244( b ), ( d )] This area for Court use only. I. EMPLOYEE INFORMATION 1. S TATE F ILE # : 2. SOCIAL SECURITY NO : 3 . DATE OF INJURY : 4. FIRST NAME : 5. MIDDLE INITIAL : 6. LAST NAME : 7. ADDRESS : 8. CITY : 9. STATE : 10. ZIP : 11. COUNTY & STATE OF RESIDENCE A T CONCLUSION OF CASE COUNTY : S TATE : 12. COUNTY & STATE OF RESIDENCE AT TIME OF INJURY : COUNTY : STATE : 13. I NSURER F ILE # : 14. DATE OF BIRTH : 15. DATE OF HIRE : 16. EDUCATION LEVEL : SOME COLLEGE / ASSOC DEGRE E LESS THAN 9TH BS / BA SOME HIGH SCHOOL GRADUATE/ PROFESSIONAL GED HIGH SCHOOL DIPLOMA 17. ABLE TO RETURN TO PRIOR EMPLOYMENT? YES NO 18. REASONABLY TRANSFERR ABLE JOB SKILLS ? YES NO 19. READ & WRITE AT 8 TH GRADE LEVEL ? YES NO II. CLAIM/INJURY INFORMATION 2 0. INJURY OCCURRED : IN TN OUT OF STATE 21. TN COUNTY INJURY: 22. AVERAGE WEEKLY WAGE: 23. WEEKLY COMP RATE 24. NATURE OF PRIMARY IN JURY / ILLNESS : 25. BODY PART : 26. WAS CLAIM DENIED ? YES NO 27. IF YES TO 26 , STATE BASIS OF DENIA L : STATUTE OF LIMITATIO NS , NOTICE , NOT WORK RELATED , INTOXICATED / POSITIVE DRUG TEST , OTHER , SPECIFY , 28. WAS SURGERY PERF ORMED ? YES NO 29. WAS PSYCHOLOGICAL IN JURY CLAIMED ? YES NO 30. WAS PSYCHOLOGICAL IN JURY SOLE CLAIM ? YES NO 31. DID EMPLOYEE RETURN TO WO RK FOR SAME EMPLOYER ? YES NO 32. RETURN TO WORK PAY W AS : LESS , SAME , HIGHER 33. DATE OF FIRST TTD PA YMENT : 34. FIRST DATE OUT OF WO RK : 35. FINAL RETURN TO WORK DATE : 36. TOTAL NUMBER OF DAYS LOST : 37. MMI DATE : 38. DATE RETURNED TO WOR K BY PHYSICIAN : 39. IS EMPLOYEE CURRENTL Y EMPLOYED ? YES NO 40. IS EMPLOYEE CURRENTL Y RECEIVING SOCIAL S ECURITY DISABILITY ? YES NO 41. DID INJURY RESULT IN DEATH ? YES NO IF YES , THEN LIST DATE OF BI RTH , AND RELATIONSHIP OF ALL DEPENDENTS : 4 2 . CLAIMS ADMINISTRATOR OR TPA FIRM NAME : ( If Different From Insurance Ca rrier ) 4 3 . CLAIMS ADM / TPA FEIN : 4 4 . ADDRESS : 4 5 . CITY : 4 6 . STATE : 4 7 . ZIP : 48 . NAME OF CASE MGMT PR OVIDER : III. EMPLOYER INFORMATION 49 . EMPLOYER NAME : ( not parent co., DBA where injured employee works ) 50 . FEIN : 5 1 . ADDRESS : 5 2 . CITY : 5 3 . STATE : 5 4 . ZIP : 55 . DID EMPLOYER HAVE A CERTIFIED DRUG FREE WORKPLACE PROGRAM ? YES NO 56 . I F SELF INSURED , NAME OF SELF INSURED PROGRAM 57. S ELF INSURED PROGRAM FEIN Pg 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com S TATE F ILE # SOCIAL SECURITY NO : DATE OF INJURY : FORM SD1 LB-0904 (REV. -) RDA 10183 5 8 . NAME OF INSURANCE CA RRIER : 5 9 . INSU RANCE CARRIER FEIN : 60 . ADDRESS : 61 . CITY : 62 . STATE : 63 . ZIP : IV. MEDICAL AND VOCATIONAL EXPERTS NAMES OF TREATING PH YSICIANS 64 . ( A ) L AST NAME : (B) FIRST ( C ) MI: ( D ) T ITLE : MD DO DC ( E ) LICENSE NUMBER : ( F ) IMPAIRMENT RATING (%) (G) TO BODY OR SPECIFIC MEMBER: ( H ) SCHE D ULED MEMBER LOCATION LEFT RIGHT ( A ) L AST NAME : (B) FIRST ( C ) MI: ( D ) T ITLE : MD DO D C ( E ) LICENSE NUMBER : ( F ) IMPAIRMENT RATING (%) (G) TO BODY OR SPECIFIC MEMBER: ( H ) SCHE D ULED MEMBER LOCATION LEFT RIGHT EMPLOYEE S IME ( s ) 65 . ( A ) L AST NAME : (B) FIRST ( C ) MI: ( D ) T ITLE : MD DO DC ( E ) LICENSE NUMBER : ( F ) IMPAIRMENT RATING (%) (G) TO BODY OR SPECIFIC MEMBER: ( H ) SCHE D ULED MEMBER LOCATION LEFT RIGHT EMPLOYER S IME ( s ) 66 . ( A ) L AST NAME : (B) FIRST ( C ) MI: ( D ) T ITLE : MD DO DC ( E ) LICENSE NUMBER : ( F ) IMPAIRMENT RATING (%) (G) TO BODY OR SPECIFIC MEMBER: ( H ) SCHE D ULED MEMBER LOCATION LEFT RIGHT EMPLOYEE S VOCATIONAL EXPERT 6 7 . ( A ) L AST NAME : (B) FIRST ( C ) MI: ( D ) T ITLE : PHD MA OTHER ( E ) VOCATIONAL DISABILIT Y RATING : EMPLOYER S VOCATIONAL EXPERT 6 8 . ( A ) L AST NAME : (B) FIRST ( C ) MI: ( D ) T ITLE : PHD MA OTHER ( E ) VOCATIONAL DISABILIT Y RATING : CHIROPRACTIC / PHYSICAL THERAPY 69 . CHIROPRACTIC TREATME NT ? YES NO I F YES , NUM BER OF VISITS ? 70 . PHYSICIAL THERAPY ? YES NO IF YES , NUMBER OF VISITS ? V. TYPE OF CONCLUSION AND COURT IDENTIFICATION INFORMATION TRIAL (Applicable only when the case has been TRIED by the court .) SETTLEMENT APPROVED BY COURT - COMPLAINT FILED (Applicable only when a lawsuit has been initiated by the filing of a complaint and summons.) SETTLEMENT APPROVED BY COURT - COMPLAINT NOT FILED. (Applicable only when a lawsuit has NOT been initiated by the filing of a complaint 71 . STYLE OF CASE : 72 . COURT DOCKET NO : 73 . COUNTY : 74 . COURT : 75 . F ULL NAME OF TRIAL JU DGE / C HANCELLOR : 76 . DATE COMPLAINT FILED : 77 . DATE OF TRIAL : 78 . DATE JOINT PETITION FILED : 79 . DATE OF SETTLEMENT A PPROVAL : 80 . NAME OF APPROVING JU DGE / CHANCELLOR SETTLEMENT APPROVED BY DEPARTMENT OF LABOR & WORKFORCE DEVELOPM ENT (Applicable only w hen the approval is by the Department.) 81 . DATE OF SETTLEMENT A PPROVAL BY SPECIALIS T : 82 . NAME OF SPECIALIST A PPROVING SETTLEMENT : VI. BENEFIT REVIEW CONFERENCE 83 . DATE OF CONFERENCE : 84 . SETTLED ? YES NO 85 . NAME OF SPECIALIST : VII. TRIAL RESULTS 86 . PPD % YES NO I F YES , NUMBER OF WEEKS ? TO BODY OR SPECIFIC MEM B ER : LEFT RIGHT 8 7 . PTD ? YES NO I F YES , NUMBER OF WEEKS ? 8 8 . DEATH CLAIM ? YES NO 8 9 . JUDGMENT FOR EMPLOYE R ? YES NO , SELECT BASIS : STATUE OF LIMITATION S ; NOTICE ; NOT WORK RELATED ; NO PERMANENCY ; I NTOXICATION ; WILLFUL MISCONDUCT ; OTHER , SPECIFY Pg 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com S TATE F ILE # SOCIAL SECURITY NO : DATE OF INJURY : FORM SD1 LB-0904 (REV. -) RDA 10183 VIII. SETTLEMENT TERMS 90. PPD % YES NO I F YES , NUMBER OF WEEKS ? TO BODY OR SPECIFIC MEM B ER : LEFT RIGHT 91 . PTD ? YES NO I F YES , NUMBER OF WEEKS ? 92 . DEATH CLAIM ? YES NO 93 . FUTUR E MEDICAL EXPENSE : CLOSED ; OPEN FOR LIFE ; OR , OPEN FOR A SPECIFIED PERIOD ? 94 . WAS MONEY PAID TO CL OSE FUTURE MEDICALS ? YES NO 95 . DATE MEDICALS WERE O R WILL BE CLOSED : 96 . WAS CASE SETTLED PUR SUANT TO TCA 50 - 6 - 206( b )? YES NO IX. SECOND INJURY FUND 97 . I S THIS A SECON D INJURY FUND CLAIM ? YES NO 98 . WAS JUDGMENT ENTER ED AGAINST SECOND INJURY FUND ? YES NO 99 . APPORTIONMENT : (1) EMPLOYER ; %; # WKS ; TOTAL AMT . (2) SECOND INJ FUND %; # WKS ; TOTAL AMT . X. MONETARY AMOUNTS PAID TYPE OF BENEFIT PAID PRIOR TO TRIAL / SETTLEMENT PAID PURSUANT TO TRI AL RESULTS PAID PURSUANT TO SETTLEMENT TERMS TOTAL PAYMENTS 100 . TEMP TOTAL DISABILIT Y 101 . TEMP PARTIAL DISABIL ITY 102 . PERMANENT PARTIAL DI SABILITY 103 . PERMANENT TOTAL DISA BILITY 104 . DEATH BENEFITS 105 . BURIAL EXPENSES 106 . MEDICAL EXPENSES TOT AL ( includes medicine, PT , chiro, hospital, MD / DO costs, tests) 107 . CASE MANAGEMENT COST S 108 . DISCRETIONARY COSTS 1 09 . AMOUNT PAID TO CLOSE FUTURE MEDICAL EXPEN SE 1 10 . LUMP SUM PAYMENT ( not based on specific disability % ) 111 DATE LUMP SUM PAID (not based on specific disability %): 1 12 . TOTALS ( ADD TOTALS FROM LINE S 100 THRU 1 10 ) 1 13 . AMOUNT PAID IN LUMP SUM FROM LINES 100 THRU 105 ; ( DO NOT ADD THIS AMOU NT TO TOTAL PAYMENTS . IT IS ALREADY INCLUD ED IN THE TOTALS ABO VE .) 1 14 . DATE LUMP SUM PAID F ROM LINES 100 THRU 105 XI. ATTORNEYS FEES 1 15 . EMPLOYEE S ATTORNEY FEE ; AMOUNT OF AWARD % OF AWARD 1 16 . WAS FEE APPROVED BY COURT OR TDLWD 1 17 . EMPLOYER S ATTORNEY FEE ( SPECIFY RANGE ): U NDER $1500 ; $1501 - 3000 ; $3000 - $10,000 ; O VER $10,000 XII. CERTIFICATION AND SIGNATURES By providing my BPR number and my signature, I hereby certify that I have read the contents of the form and the information prov