Johnson, Terry v. Papa John's a/k/a Patriot Pizza. LLC

FILED
Jun 24, 2020
08:34 AM(CT)
TENNESSEE COURT OF
WORKERS' COMPENSATION
CLAIMS

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

TERRY JOHNSON, ) Docket No. 2017-07-0640
Employee, )
v. )
PAPA JOHN'S a/k/a PATRIOT ) State File No. 46304-2016
PIZZA, LLC, )
Employer, )
And ) Judge Allen Phillips
STATE FARM FIRE & CAS. CO., )
Carrier, )

COMPENSATION HEARING ORDER

This case came before the Court on May 27, 2020, for a Compensation Hearing.
The issues were the extent of Mr. Johnson's permanent disability, whether the benefits
should be commuted to a lump sum, and payment of attorney's fees and costs. For the
following reasons, the Court holds that Mr. Johnson is permanently and totally disabled. It
addresses the remaining issues below.

History of Claim

Mr. Johnson's irzjury and treatment

On May 14, 2016, Mr. Johnson was involved in a motor vehicle accident while
delivering pizzas for Papa John's. He required air transport to Vanderbilt Medical Center.

At Vanderbilt, Mr. Johnson was diagnosed with multiple injuries, including:

• Diffuse axonal injury to the brain;
• Frontal subdural hematoma;
• Subarachnoid hemorrhage;
• Facial and scalp lacerations;
• Right cranial nerve injury affecting the right eye;
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• Bilateral femur fractures; and
• Fractures of the left wrist and small finger.

Mr. Johnson was treated by many providers at Vanderbilt, including orthopedic
trauma surgeon Dr. Manish Sethi. On May 17, Dr. Sethi surgically repaired the femur
fractures, and at the same time other surgeons attended to Mr. Johnson's left-wrist and
finger fractures. Dr. Sethi testified in his deposition that Mr. Johnson's condition was so
grave when he first saw him that he "frankly, did not expect him to survive." He described
Mr. Johnson's right femur as "completely destroyed," and his left femur as "almost
completely destroyed."

After the initial surgery, Mr. Johnson remained hospitalized at Vanderbilt through
June 24. Plastic surgeons repaired the facial and scalp lacerations, ophthalmologists were
consulted for the right-eye injury, and neurosurgeons placed a drain to relieve pressure
from his brain. A serious complication arose when he developed a bowel blockage and
required removal of a large portion of his colon with placement of a colostomy bag. He
then developed blood clots in his lungs.

After treatment for those conditions, Mr. Johnson was admitted to Stallworth
Rehabilitation Center and underwent therapy for his leg and traumatic brain injuries. He
was discharged home on July 27 with an order for 24-hour supervised care. Papa John's
then began paying Mr. Johnson's wife approximately $3,500 per month to serve as his
caregiver, an arrangement that continued as of the hearing.

Once home, Mr. Johnson continued medical treatment and evaluation over the next
two years. 1 On October 30, 2016, Dr. Jeffrey Uzzle performed a Social Security disability
evaluation. He recorded the history of Mr. Johnson's multiple injuries but noted "his
fiancee completed his paperwork for him." Dr Uzzle found Mr. Johnson's right eye was
closed and that his visual acuity was only 20/200 when it was opened for testing. He said
Mr. Johnson had a driver's license but could not drive because of the brain injury. Dr Uzzle
observed him walking with a "slow, but functional gait pattern" and that he had poor
balance. He described Mr. Johnson as "anxious" but cooperative.

Regarding restrictions, Dr. Uzzle believed Mr. Johnson could "occasionally" lift or
carry up to twenty pounds but could only lift or carry ten pounds "frequently." He said he
could walk for up to thirty minutes at a time and for up to four hours per day but added he
needed a cane to do so. Dr. Uzzle said Mr. Johnson should never climb ladders, work at
heights, move mechanical parts, or operate a motor vehicle.

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The Court summarizes the medical treatment as pertinent based on review of the stipulated medical records
consisting of several hundred pages.

2
In January 2018, Dr. Ken Berry completed a Social Security disability evaluation in
which he stated that Mr. Johnson could lift ten pounds only occasionally but never carry
any weight. He said he could never climb, balance, stoop, kneel, crouch, or crawl. Dr. Berry
said Mr. Johnson could not use either hand to push, pull or reach, and that he could not
drive. Due to his eye injury, which Dr. Berry described as a "blind" right eye, Mr. Johnson
could not avoid hazards in the workplace, read small print or a newspaper, or view a
computer screen. He said Mr. Johnson could not perform activities such as shopping, and
that he should not travel without a companion for assistance.

In February 2018, Mr. Johnson saw Dr. Mark Phillips, a clinical neuropsychologist,
for evaluation of the traumatic brain injury. Dr. Phillips found Mr. Johnson suffered from
memory deficits and poor insight, and that he was dependent upon his caregiver. His poor
memory manifested with trouble recalling names and events before the accident. His
caregiver prepared his meals, as he no longer cooked, and she did all driving. Dr. Phillips
determined Mr. Johnson could not manage his own finances. From the physical standpoint,
Dr. Phillips noted Mr. Johnson's reports that he required assistance when entering and
exiting the bathtub and putting on socks, and that he limited his eating due to urgency and
incontinence.

Dr. Phillips conducted neurological and psychological testing that revealed a "Major
Neurocognitive Disorder" due to the traumatic brain injury. This disorder manifested not
only in Mr. Johnson's memory deficits but also in a poor attention span, problems with
language, impaired visual-motor function, and decreased reasoning. Because of his
condition, Dr. Phillips said Mr. Johnson needed twenty-four-hour in-home care.

Expert proof

Dr. Sethi last saw Mr. Johnson in August 2018. He noted Mr. Johnson was "limping
quite extensively" and repeated, "I was just amazed the guy's alive." He called Mr.
Johnson's impairment from his leg injuries "pretty devastating," akin to "someone with a
brain injury and this guy already had a brain injury." Due to the leg injuries, Dr. Sethi said
Mr. Johnson should limit his walking and restrict his lifting to fewer than five pounds.

Dr. Sethi provided a twenty-percent impairment rating for the leg injuries but added
he might have "underestimated it." He also said the total impairment from all injuries
"would be much higher." As to returning to work, Dr. Sethi told Mr. Johnson he did not
think he could return to a "normal job." He added, "frankly, if the guy can live any
semblance of a normal life, I think it's good."

Dr. Samuel Chung testified by deposition. He is a physical medicine specialist and
certified independent medical examiner who saw Mr. Johnson at the request of his attorney.
Dr. Chung took a detailed history, reviewed the extensive medical records, and evaluated
Mr. Johnson for all injuries other than the legs. He noted that Mr. Johnson almost fell in

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the examination room. He assessed a total impairment rating of fifty-two percent to the
body based on the following impairments under the American Medical Association
Guidelines to the Evaluation ofPermanent Impairment, 6th Edition:

• Twenty percent impairment for the traumatic brain injury due to altered
mental status, and cognition of a moderate degree, and the impact of these on Mr.
Johnson's activities of daily living based on Dr. Phillips's testing;
• Fifteen percent for the ileostomy with residual effects;
• Twenty-five percent for the facial disfigurement because of the right eye
injury based on distortion of the normal facial anatomy causing significant
disruption of social activity; and
• Six percent because of lost range of motion of the left wrist and left fourth
finger.

When Dr. Chung combined his fifty-two-percent rating with Dr. Sethi's twenty-
percent rating for the legs, he said Mr. Johnson has a total impairment of sixty-two percent
to the body as a whole.

Dr. Chung testified Mr. Johnson could not carry any weight and could lift only ten
pounds frequently and only occasionally with the left arm. Dr. Chung said Mr. Johnson
would be unable to be on his feet and lift items because he needed a cane to ambulate. He
perceived Mr. Johnson to be a danger to others in a work setting due to his brain injury,
noting that he could only focus for "less than two to three minutes." Like Drs. Uzzle and
Berry, Dr. Chung said Mr. Johnson could not drive or work around moving mechanical
parts. He said Mr. Johnson's poor insight caused him to "not always be aware of what his
deficits are."

Dr. Robert Kennon, a licensed psychologist and vocational expert, testified at trial
on behalf of Mr. Johnson. Dr. Kennon interviewed Mr. Johnson and performed a battery
of testing to evaluate his mental, psychological and vocational functioning. When he
performed his evaluation, he was concerned that Mr. Johnson might fall in his office
because of his difficulties walking.

Dr. Kennon's mental and psychological testing revealed that Mr. Johnson
functioned with "borderline intellectual ability," with an IQ of only seventy-five, which
placed him in the fifth percentile. He has a seventh-grade sentence comprehension ability,
a fourth-grade spelling equivalency, and third grade-level math skills. The mathematical
limitations were so severe that Dr. Kennon said Mr. Johnson is incapable of managing his
own finances. Further, Dr. Kennon said Mr. Johnson's cognitive and academic capacities
would prevent him from completing vocational rehabilitation, even if his physical abilities
would allow it. He noted his findings were consistent with those of Dr. Phillips. Also, like
Dr. Chung, Dr. Kennon believed Mr. Johnson does not fully grasp the extent of his injuries.

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When considering the testimony of Dr. Berry and Dr. Chung, Dr. Kennon said Mr.
Johnson had no transferable job skills in the open labor market and was 100 percent
disabled. Under the restrictions placed by Dr. Sethi, Dr. Kennon found a 99.74% loss of
moderately transferable skills (based on Mr. Johnson's prior work experience), and when
considering Dr. Uzzle's restrictions, he found an 85.97% loss of moderately transferable
skills. He found only fifteen possible jobs in a labor market survey based on Dr. Uzzle's
restrictions but noted Mr. Johnson's condition, age, and the current unemployment
situation would challenge him further. However, even if he could find a job he might
perform physically, Dr. Kennon questioned whether Mr. Johnson's cognitive function
would allow him to work because of his decreased memory, lack of insight and attention
to detail, and inability to sequence tasks.

Lay testimony

Mr. Johnson testified he had no memory of the accident and only limited memory
of his life before it. He remembers waking up at the Stallworth Center, where he said he
stayed to "help me get my legs moving." He can remember completing high school and
working in the restaurant industry. He does not think he could work now.

Mr. Johnson said he needs help walking and now uses a walker rather than a cane.
He can stand "for a minute or two." He has trouble climbing steps and can neither kneel
nor squat. He has pain in his legs up to his hips and cannot open his right eye. He lifts
nothing because of the abdominal injury, and he cannot flex his left hand.

Mr. Johnson described his fear of urgent bowel movements and said he uses the
restroom at least six times per day. He monitors his eating and consumes smaller portions
to avoid urgency. He spends his days at home and does no "chores" around the house. He
scarcely leaves his home, but when he does, it is always with his wife, who drives them.
He currently draws Social Security disability benefits.

Crystal Johnson testified she was living with Mr. Johnson at the time of the accident.
They married in 2019. She said her husband was in a coma for two months and then
Stallworth for another month, a time that she never left her husband's side, allowing her to
observe his condition. She said Mr. Johnson has "gotten worse" over the last eighteen
months and can "barely walk." He can stand for no more than ten minutes maximum and
he does not fall "because I'm right there." She said she has to "help him up," and that "he
goes everywhere with me." She described his lack of interest in leaving home because of
his bowel urgency, and she noted he is quick to anger and has poor memory. She manages
the family finances.

Mrs. Johnson quit her job to care for her husband, and the worker's compensation
carrier pays her $3,456 every four weeks to do so. That payment, along with Mr. Johnson's
approximately $600 per month Social Security check, is the family's income. She testified

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their bills were "current," and that any lump-sum payment of benefits in this case would
go to pay off their house.

Based on this evidence, Mr. Johnson claimed he was totally disabled; Papa John's
argued he was not. It also argued there was no "special need" for lump-commutation, as
the family income was approximately $50,000 per year with Social Security benefits and
payments to Mrs. Johnson as his caregiver.

Findings of Fact and Conclusions of Law

At a Compensation Hearing, Mr. Johnson must establish all elements of his case by
a preponderance of the evidence. Tenn. Code Ann. § 50-6-239(c)(6) (2019).

Extent ofpermanent disability

The extent of Mr. Johnson's disability is a question of fact determined by
consideration of all the evidence, both expert proof and lay testimony. Duignan v. Stowers
Mach. Corp., No. E2018-01120-SC-R3-WC, 2019 Tenn. LEXIS 224, at *22 (Workers'
Comp. Panel June 19, 2019). The relevant factors are Mr. Johnson's skills, training,
education, age, local job opportunities, and ability to work at available jobs in his post-
injury condition. Id. Although a vocational expert assessed these factors, Mr. Johnson's
testimony concerning his ability to return to work is "competent testimony" that the Court
should consider. Hubble v. Dyer Nursing Home, 188 S.W.3d 525, 536 (Tenn. 2006). He is
entitled to an award of PTO benefits if his injury "totally incapacitates [him] from working
at an occupation that brings [him] an income." Tenn. Code Ann. § 50-6-207(4)(B).

The Court turns first to the expert proof. Dr. Sethi restricted Mr. Johnson to lifting
no more than five pounds. Dr. Berry restricted him to no more than ten. Dr. Uzzle was
slightly more generous, but still said Mr. Johnson should never lift or carry more than
twenty pounds and only ten pounds frequently. Dr. Sethi did not think Mr. Johnson could
return to work.

When considering the restrictions of Dr. Sethi and Dr. Berry, Dr. Kennon testified
Mr. Johnson has no transferable job skills. When considering Dr. Uzzle's restrictions, Dr.
Kennon found only fifteen jobs in his labor market survey that Mr. Johnson might perform
physically. However, Dr. Kennon doubted Mr. Johnson could do those because of his
impaired mental functioning.

As to the lay evidence, the Court observed Mr. Johnson ambulate in and about the
courtroom during a three-plus hour hearing. His gait was unsteady, unbalanced, and aided
constantly by a walker. His wife was always close by to assist. His impaired movement
appeared exactly as described by the physicians. Based on direct observation, the Court
does not believe he could physically function in any work setting.

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Likewise, the Court heard Mr. Johnson's slow and deliberate manner of speaking.
When he was not speaking, the Court observed that Mr. Johnson sat quietly, unable to open
his right eye and often closing his left. The scarring from his scalp and facial injuries was
evident. He appeared detached from the proceedings, and like the physicians described,
somewhat unaware of the extent of his disability. Nevertheless, both in his speech and by
his demeanor, the Court finds him credible. He was calm, forthcoming, and honest, and
considering his condition, very reasonable in explaining the effects of his injury. See, Kelly
v. Kelly, 445 S.W.3d 685, 694-695 (Tenn. 2014) (discussing indicia of witness credibility).

Those effects were obvious from his testimony. He seldom leaves the house, and
when he does, his wife accompanies him, always driving because he cannot. He described
his problems walking and that he often needs help to do so. He cannot see with his right
eye or lift anything. His days are spent at home, where he does very little. He has a very
real fear of his frequent urgency to use the restroom.

Mr. Johnson's wife echoed the problems Mr. Johnson described. She cares for him
constantly and manages their finances because he cannot. She says he does not fall only
because she is "right there." She noted his quickness to anger, poor memory, and urgency
to use the restroom. Further, the Court finds it particularly telling that the carrier pays her
approximately $3,500 per month to care for her husband.

Considering both the medical and lay proof, the Court holds Mr. Johnson's injuries
totally incapacitate him from working at an occupation that brings him an income and that
he is permanently and totally disabled under Tennessee Code Annotated section 50-6-
207(4)(B).

Calculation of benefits

Under section 207(4)(B), Mr. Johnson is entitled to payment of PTD benefits until
he becomes eligible for full Old Age Social Security benefits. Papa John's did not contest
that Mr. Johnson will become eligible for those benefits when he reaches age 67 on
December 31, 2033. Thus, the Court looks to the date Papa John's last paid temporary
disability,2 December 9, 2018, as the starting date of Mr. Johnson's permanent disability.
The time period from that date until December 31, 2033, is 785 weeks and six days. At the
stipulated weekly compensation rate of $128. 70, the benefits payable for the entire period
of disability equal $101,139.84. The accrued benefits from December 9, 2018, through
June 24, 2020, a period of 80 weeks and four days, shall be paid to Mr. Johnson in a lump
sum of $10,369.36.

2Papa John's paid temporary disability benefits through December 9, 2018, beyond the date of his
maximum medical improvement on August 13, 2018. Thus, the calculation of PTO benefits begins with
December 9.
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Lump-sum commutation

Mr. Johnson moved the Court to commute the remaining amount of his disability
benefits to a lump sum. The Court cannot do so. Tennessee Code Annotated section 50-6-
207(4)(A)(ii)(a) provides that PTD benefits "may be commuted to a lump sum to pay only
the employee's attorney's fees and litigation expenses and to pay pre-injury obligations in
arrears." Even then, the "commuted portion of an award shall not exceed the value of one
hundred (100) weeks of the employee's benefits." Id. at (ii)(b).

Here, the Court finds it appropriate to commute 100 weeks of the award to pay Mr.
Johnson's attorney's fees and litigation expenses. Tennessee Code Annotated section 50-
6-229(a) allows commutation of attorney fees if"approved and ordered by the trial judge."
Further, in Spencer v. Towson Moving & Storage, 922 S.W.2d 508, 511 (Tenn. 1996), the
Tennessee Supreme Court noted that payment of attorney fees in a lump sum avoids costly
administrative burdens and delays caused by periodic payments first going to the attorney
for deduction of fees. It is in Mr. Johnson's best interest to prevent delay. Thus, the Court
commutes 100 weeks of the award and orders Papa John's to pay it in a lump sum of
$12,870 (100 weeks times $128.70).

Attorney's fees

As to the amount of the fee, Tennessee Code Annotated section 50-6-207(4)(a)(iii)
provides that fees in PTD cases "shall be calculated upon the first four hundred and fifty
(450) weeks of disability only." Further, under section 226(a)(l), any attorney fee shall not
exceed twenty percent of the award.

Because a twenty-percent fee here would exceed $10,000, the Court asked
employee's counsel to submit an affidavit supporting it. See Tenn. Code Ann. § 50-6-
226(a)(2(C). In his affidavit, counsel stated that he has practiced law for forty-seven years,
he expended extensive time and expense prosecuting the case, and he had a written
agreement for fees and expenses.

The Court finds these assertions support a twenty-percent fee. Specifically, the
Court considers the factors in Tennessee Supreme Court Rule 8, RPC 1.5. The relevant
factors here are the results obtained, the amount of work required, the customary fee set
forth in a written agreement, and counsel's experience and reputation.

Thus, of the 100-week commutation, counsel may take an attorney fee of $11,583
(450 weeks times twenty percent times $128.70). The remaining balance of the 100-week
commutation might be used for payment of counsel's expenses.

Papa John's attorney's fees also exceeded $10,000, and the Court asked its counsel
to submit an affidavit. Counsel set forth his thirty-three years of practice, his reputation

8
and ability, and the substantial time expended. For the same reasons as the employee's
attorney, the Court finds employer's counsel's fees were appropriate and approves them.

Recalculation ofpayments

Section 207(4)(ii)(c) requires that after the commuted lump sum is determined, the
amount of the weekly PTD payments shall be recalculated to distribute them in equal
weekly installments over the entire period of disability. Here, the remaining PTD benefits
after commutation equal $77,990.48 ($101,139.84 less the accrued benefits of $10,369.36
and the 100-week commutation of$12,780).

However, the recalculation provided under section 207(4)(ii)(c) is proscribed in this
case. Mr. Johnson's stipulated compensation rate is $128.70 per week, the minimum
weekly benefit for his date of injury. If the Court recalculates the weekly payments to
distribute them over the period of disability, then Mr. Johnson would receive weekly
periodic payments in an amount less than the minimum weekly benefit. Because section
207(4)(B) provides that "in no event shall the compensation paid [for PTD] be less than
the minimum weekly benefit," the Court holds that Papa John's shall pay the remaining
balance of$77,990.48 in periodic payments of $128.70 per week until paid in full.

Discretionary costs

Mr. Johnson moved for payment of his discretionary costs. Papa John's did not
contest the motion. Thus, the Court orders Papa John's to pay Mr. Johnson's discretionary
costs of $5,203.40 as itemized in Technical Record Exhibit 18.

Medical expenses

Finally, Mr. Johnson claimed one medical bill was unpaid. Papa John's did not
dispute it. The Court orders that Papa John's pay any outstanding past medical expenses
and further orders it pay for Mr. Johnson's future medical expenses under Tennessee Code
Annotated section 50-6-204(a)(l)(A). It shall designate the authorized physician.

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IT IS, THEREFORE, ORDERED as follows:

1. Papa John's shall pay Mr. Johnson permanent total disability benefits of
$101,139.84 for the period of December 9, 2018, through December 31, 2033.
It shall pay the accrued benefits from December 9, 2018, through June 24, 2020,
in a lump sum of$10,369.36 and pay 100 weeks of commuted benefits in a lump
sum of $12,780 to pay for attorney's fees and expenses. The remaining
$77,990.48 shall be paid periodically at the rate of $128.70 per week until fully
paid.

2. Papa John's shall pay all reasonable and necessary past and future medical
benefits under Tennessee Code Annotated section 50-6-204(a)(l)(a).

3. Papa John's shall pay Mr. Johnson's discretionary costs of $5,203.40.

4. The Court approves the fees of both attorneys.

5. The Court taxes the $150.00 filing fee to Papa John's to be paid to the Court
Clerk under Tennessee Compilation Rules and Regulations 0800-02-21-.06
(August, 2019) within five business days of this order becoming final, and for
which execution might issue if necessary.

6. Papa John's shall file a Statistical Data Form (SD-2) with the Court Clerk within
five business days of the date this order becomes final.

7. Absent an appeal, this order shall become final thirty days after entry.

ENTERED June 24, 2020.

&~~-
Judge Allen Phillips ~r
Court of Workers' Compensation Claims
APPENDIX

Exhibits
1. Deposition of Dr. Manish Sethi
2. Deposition of Dr. Samuel Chung
3. Collective Medical records
4. Payment history of Medical Bills
5. Payment history of Temporary Disability Benefits
6. Copy of Mr. Johnson's Driver's License
7. Dr. Kennon's Report

Technical Record
1. Petition for Benefit Determination
2. Dispute Certification Notice
3. Scheduling Order
4. Order on Filing of Medical Records
5. Order Granting Summary Judgment to Subsequent Injury Fund
6. Motion to Extend Deadlines
7. Order Extending Deadlines
8. Motion for Discretionary Costs
9. Motion for Commutation of Attorney's Fees
10. Motion for Commutation of Award
11. Employee's Witness and Exhibit List
12. Post-discovery Dispute Certification Notice
13. Employee's Brief and Pre-Compensation Hearing Statement
14. Employer's Exhibit List
15. Employer's Witness List
16.Employer's Pre-Hearing Statement
17. Employee's Supplemental Motion for Discretionary Costs
18.Employee's Second Supplemental Motion for Discretionary Costs
19. Order of Continuance
20. Stipulation of medicals attached to Dr. Chung's deposition
21. Second Order of Continuance
22. Third Order of Continuance

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CERTIFICATE OF SERVICE

I certify that a copy of this Order was sent as indicated on June 24, 2020.

Name Via Service sent to:
Email
Charles L. Hicks, X larry_hickslaw@bellsouth.net
Attorney for Employee shearon hickslaw@bellsouth.net
Robert 0. Binkley, Jr., X rbinkley@raineykizer.com
Attorney for Employer

Pennynim, Court Clerk
wc.courtclerk@tn.gov

12
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, ifrepresented).

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 oflndigency 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 fzfteen 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
hasfzfteen 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/work.force/injurles-at-
Y:!_Qill_
wc.courtclerk@tn.gov I 1-800-332-2667

Docket No.: _ _ _ _ _ _ _ _ __

State File No.: _ _ _ _ __ _ _ _

Date of Injury: _ _ _ _ _ _ _ __

Employee

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ 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): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D Employer D 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 lnj .: _ _ _ __

Appellee(s) (Opposing Party) : □ Employer □ Employee
- - - - - - - - -- -- - - -- - - -
App e II ee'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
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:
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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: _ _ _ _ _ _ __ _ __ _

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 Comp.$ per month beginning
Other $ per month beginning

LB-1108 (REV 11/15) RDA 11082
9. My expenses are:

RenUHouse Payment $ per month Medical/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

_ _ _ day of _ _ _ _ _ _ _ _ _ _ _ , 20_ __

NOTARY PUBLIC

My Commission Expires: _ _ _ _ _ _ __

LB-I I 08 (REV 11/15) RDA 11082