Petition For Benefit Determination {LB-1120}

LB 1120 - PETITION FOR BENEFIT DETERMINATION. This form is for settlements approved by the Tennessee Bureau of Workers' Compensation. It is used in cases involving work-related injuries that occurred on or after July 1, 2014. The form collects various details related to the injury, such as the date of injury, description of the injury, and whether the case was mediated by Mediation and Ombudsman Services of Tennessee. It also gathers information about the employee, including their name, date of birth, mailing address, and contact details. Additionally, it requests information about the employer, their attorney, the insurance carrier, and any third-party administrators involved. The form concludes with a request for approval of the proposed settlement agreement, to be signed by both the employee (or their representative) and the employer (or their representative). www.FormsWorkflow.com