# Havey, Julia v. 2024-60-3630

> Tennessee Court of Workers' Compensation Claims · April 23, 2025 · 2025 TN WC 21

URL: https://www.frixlaw.com/law-library/cases/10850940

## Case

- **Court:** Tennessee Court of Workers' Compensation Claims
- **Decided:** April 23, 2025
- **Citations:** 2025 TN WC 21
- **Precedential status:** Published
- **Opinion:** Opinion
- **Judges:** Switzer
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

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## Opinion text

FILED
Apr 23, 2025
11:35 AM(CT)
TENNESSEE COURT OF
WORKERS' COMPENSATION
CLAIMS

TENNESSEE BUREAU OF WORKERS’ COMPENSATION
IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT NASHVILLE

Julia Havey, ) Docket No. 2024-60-3630
Petitioner, )
v. )
SageHome, LLC d/b/a New Bath ) State File No. 38543-2024
Today, )
Respondent, )
And ) Judge Kenneth M. Switzer
American Fire & Cas. Co., )
Carrier. )

EXPEDITED HEARING ORDER

Julia Havey, who worked as a sales representative for New Bath Today, slipped and
fell while carrying heavy sample bags outside a customer’s home. New Bath Today did
not dispute the event or her injuries but instead raised the defense that Ms. Havey is an
independent contractor and therefore ineligible for benefits.

New Bath Today mostly contended that the agreement between them characterizes
her as an independent contractor. Ms. Havey countered that the Court should look beyond
those words and consider the level of control New Bath Today exerted, which is
characteristic of an employer-employee relationship. After an April 16, 2025 hearing, the
Court concludes that Ms. Havey is likely to prevail at a hearing on the merits that she was
an employee. New Bath Today must offer a panel of physicians.1

Claim History

Ms. Havey began working for New Bath Today in May 2023. She had been looking
for “a 1099 job that would give [her] autonomy and freedom,” and was less rigorous than
1
Ms. Havey named “New Bath Today” as her employer on the petition, but the dispute certification notice
lists the employer as “CC 1 US Holdings, Inc.” New Bath Today’s counsel clarified at the hearing that CC
1 US Holdings is the parent corporation and SageHome, LLC d/b/a New Bath Today is its subsidiary and
the correct respondent.
1
her previous, high-pressure sales job. A recruiter told her she could “work a lot or a little”
to include a four-day work week if she wanted.

This case centers on an agreement she signed when hired. The 21-page, single-
spaced document includes two exhibits and is entitled, “Sales Representative Agreement
(Independent Contractor).” Ms. Havey understood she would be an independent
contractor, emphasizing, “I was promised not to be treated like an employee.” Specifically,
she wanted to get leads, pursue them at her leisure, and place fewer physical demands on
her body than her previous jobs.

Ms. Havey testified that did not happen. Despite the agreement, New Bath Today
treated her as an employee, mostly by controlling her work in several ways.

The job began with two weeks of required onsite intensive training in Indiana. Ms.
Havey was not reimbursed for her mileage driving there and back. New Bath Today
fronted her lodging but later took $1,000 from her pay as reimbursement. It provided
sandwiches and snacks during the day and a per diem for other meals.

At training, New Bath Today loaded software and an app, which she had to purchase
and pay a monthly fee to use, onto Ms. Havey’s personal tablet computer. She was required
to use her own mobile phone. Training consisted mostly of memorizing a lengthy
“timeline,” or six-page script, for required use when making sales calls. They were to
recite the script verbatim, but some customization was permitted with the company’s
approval. Training culminated with “graduation,” after Ms. Havey performed the script
for management. Ms. Havey was then given business cards with the New Bath Today logo
identifying her as a “design consultant.” The cards gave her phone number along with the
number of New Bath Today’s corporate office. Ms. Havey also received marketing
materials and New Bath Today branded bags for carrying samples to sales calls.

Once she was on the job, the daily procedure kicked in. Ms. Havey would check
the app the night before a workday, which would give her leads. Ms. Havey was free to
also find her own leads, too. The leads consisted of appointments at either 10:00 a.m., 2:00
p.m., or 6:00 p.m. at a prospective customer’s home. For example, one day she had
appointments in Greenville, Kentucky; Goodlettsville; and then Spring Hill. This was a
15-hour day, she said. Ms. Havey said she was not free to alter these appointment times
and had no way to directly contact the customers before they met.

Ms. Havey testified that some days she would have three appointments, and other
times she would go for “weeks” without a single appointment. Whenever she had no
appointments, she was required to be on “standby” and available to attend any last-minute
appointments that New Bath Today might set. This meant she had to stay home while
standing by. When Ms. Havey requested to work Mondays through Thursdays, she
received negative feedback from the company, including threats of termination.

2
In addition to making sales calls, Ms. Havey testified that approximately six times
over the course of her ten months’ work for New Bath Today, she had to attend follow-up,
two-hour “trainings” whenever New Bath Today changed lenders to learn the new criteria.

Ms. Havey agreed that the agreement did not give her a quota, but the pressure to
sell was intense, nonetheless. New Bath Today required her to attend weekly Monday
meetings. The purpose of the meeting was to “incentivize” staff by discussing a 30% sales
goal and recapping who sold the most the previous week. Her direct supervisor, Matthew
Melton, “frequently admonished” her if she did not reach the 30% goal. He also told her
she could be “taken off the schedule”—in effect fired—for not selling enough. She said,
“It was the most grueling sales environment I’ve ever been in.”

Ms. Havey testified that she asked whether attendance was mandatory at the
Monday meetings, and a corporate supervisor, Mike Rouser, told her that nonattendance
was “unacceptable.” In addition, Mr. Melton sent a text that “[y]our job is to be on a
company call once a week for 8am. If you think that’s too much to ask, then you can work
elsewhere.”

New Bath Today required Ms. Havey to be accessible and responsive during work
hours. She offered a group text from Mr. Melton saying, “From 8am your time zone to
4pm, if someone calls you like myself, Mike R, call center, or anyone from corporate, there
is no option to not immediately return that call or message unless you’re in a meeting in
[sic] or some emergency.”

As for compensation, the agreement states that Ms. Havey would earn a up to a 35%
commission on all sales. She received commission only and no salary, and no taxes were
withheld. She received a 1099. Ms. Havey said she never received the full 35%
commission on any sale; “costs” were frequently deducted. More often she earned 6-8%.
For example, on a sale of $19,300, she earned a commission of 2.79%, or $538.52. Mr.
Melton earned the same on that sale.

Commissions were split 50/50, Ms. Havey explained, when a supervisor attended a
presentation, “ran the appointment,” and made the sale, while she observed and assisted.
The sales representative could alternatively ask to take the lead. The supervisor visits were
unscheduled; sometimes she would arrive at a home and see her supervisor’s vehicle.
Other times, she knew he would be attending. A supervisor attended three appointments
during her time with New Bath Today.

Ms. Havey did not hire helpers, despite the agreement giving her that right. She
explained that she would have been unable to allow a helper access to the app or sales
software. She further testified that she never heard of anyone’s “team” making a sale, but

3
rather it was always an individual. She conceded, however, that she did not know for
certain if no other sales representative had helpers.

Ms. Havey did not work for other entities during her tenure at New Bath Today.
She stated that, between being on standby or attending appointments, she had no time to
seek other employment.

As to the accident, Ms. Havey testified that on March 6, 2024, she slipped on a
customer’s sidewalk while carrying the bag of sales materials weighing approximately 45
pounds. She injured her right ankle, left hip and shoulder, and low back. That night, she
mentioned her fall in a group text with other sales representatives, adding that the company
did not provide workers’ compensation. In response, an area sales manager, “Danielle,”
wrote, “That’s because you are a 1099. You are your own business.”

Ms. Havey took a week off after the fall and agreed that New Bath Today permitted
that and other time off that she had previously requested. For example, after her father’s
death, she took six weeks off. New Bath Today allowed that, although she testified that
Mr. Melton repeatedly told her once she returned that she was “lucky” her father had died
or she would have been terminated.

Ms. Havey filed her petition on May 23, 2024, and New Bath Today denied the
claim on July 16. She testified that New Bath Today placed “exacting controls, demands
of my time, and unagreed to expectations” on her, to a level where she was an employee
and not an independent contractor. She said she will need shoulder surgery and suffers
“constant pain,” but the only admissible medical record she offered was a one-page result
from a shoulder MRI. New Bath Today later terminated Ms. Havey, and she has not
worked since. She requested a panel of physicians and temporary disability benefits.

New Bath Today’s proof was an affidavit from Jason Bisch, its senior vice-
president. Mr. Bisch did not testify about his knowledge of Ms. Havey’s tenure with the
company or the accident. Rather, the affidavit mostly restates key portions of the
agreement between New Bath Today and Ms. Havey, with Mr. Bisch concluding, “The
Agreement demonstrates that the intention of New Bath Today and Julia Havey was that
Julia Havey would be an independent contractor and not a W2 Employee.”

The agreement states in relevant part:

◼ The company and sales representative “acknowledge[] and agree[] that the Sales
Representative . . is a ‘direct seller’” as defined by the Internal Revenue Code
and therefore “will not be treated as an employee . . . for employment tax
purposes.”
◼ “The Company shall have no duty to supervise the work of the Sales
Representative” or their employees or independent contractors, and the company

4
“expressly disclaims any duty, express or implied, to supervise the work of Sales
Representative or safety of its employees and independent contractors.”

New Bath Today principally argued that under the signed agreement, Ms. Havey is
an independent contractor. But also, in practice, she was free to hire helpers, pursue her
own leads or other work, and quit at any time. Moreover, she could and did ask for time
off, which New Bath Today permitted, and she used her own tablet, phone, and purchased
software.

Law and Analysis

To support an order for benefits, Ms. Havey has the burden of presenting sufficient
evidence from which the trial court could conclude she is likely to prevail at trial in proving
she is eligible to seek benefits. Hernandez v. Master Stucco, 2023 TN Wrk. Comp. App.
Bd. LEXIS 30, at *9 (July 6, 2023).

Employee or independent contractor

The threshold issue is whether she was an employee or independent contractor. The
analysis begins with the factors listed in Tennessee Code Annotated section 50-6-
102(10)(D)(i) (2024). They are: (a) the right of control over the conduct of the work; (b)
the right of termination; (c) the method of payment; (d) the freedom to select and hire
helpers; (e) the furnishing of tools and equipment; (f) self-scheduling of work hours; and
(g) the freedom to offer services to other entities. While no single factor is determinative,
“the Tennessee Supreme Court has repeatedly emphasized the importance of the right
to control the conduct of the work.” Id. at *8-9.

New Bath Today’s denial relied largely upon the lengthy written agreement between
the parties. Its sole witness was a declarant/senior vice-president, Mr. Bisch, who merely
restated the agreement’s terms in his testimony and concluded that the parties’ “intention”
was for Ms. Havey to work as an independent contractor. He gave no testimony about the
particulars of Ms. Havey’s relationship with the company, and the Court cannot discern if
he even knew her or has any knowledge about her individual claim.

The Court affords little weight to his declaration, since he was not subject to cross-
examination. But more importantly, “Tennessee law is clear that the intent of the parties
is not dispositive on this issue.” Thompson v. Concrete Solutions, 2015 TN Wrk. Comp.
App. Bd. LEXIS 3, at *16 (Feb. 10, 2015). In addition, “the designation given by the
parties in their contract does not dictate the applicability of the Workers’
Compensation Law. Our Supreme Court has stated that ‘a contract purporting to establish
the plaintiff as an independent contractor is insufficient when the facts surrounding the
arrangement indicate [otherwise].” Id. at *16-17 (Citation omitted).

5
More recently in Hernandez, the Appeals Board cited longstanding law that:

It is the duty of the court to determine if a worker is an employee
or independent contractor, and the employer cannot use a contract to take
that responsibility from the court. The Workers’ Compensation Act similarly
prohibits the use by an employer of any ‘contract or agreement, written or
implied, or rule, regulation or other device’ to evade its workers’
compensation obligations.

Hernandez, 2023 TN Wrk. Comp. App. Bd. LEXIS 30 at *14-15 (citing Tenn. Code Ann.
§ 50-6-114(a)).

Therefore, the Court will perform its duty to apply the factors above to the facts of
this case and will not be bound solely by the terms of the written agreement—one that,
arguably, seeks to evade the Workers’ Compensation Law.

For starters, Ms. Havey emphasized without rebuttal that New Bath Today exerted
significant control over her work. They set her appointments, scripted her sales
presentations, and required her to attend weekly meetings and trainings approximately
every six weeks. New Bath Today also demanded immediate responsiveness to all
communications during business hours and that she “stand by” when appointments were
unavailable. In addition, her supervisor occasionally attended her appointments, with or
without notice, to evaluate her technique and essentially take part of her commission.

Ms. Havey’s testimony was credible and unrefuted, and she did not waver on
rigorous cross-examination. Therefore, the Court agrees that New Bath Today closely
controlled her work activities. This factor favors a finding that Ms. Havey was an
employee.

As to the right of termination, either party could have exercised this at any time.
The Appeals Board in Hernandez reminded, “The power of a party to a work contract to
terminate the relationship at will is contrary to the full control of work activities usually
enjoyed by an independent contractor.” Id. at *15. Therefore, this factor favors employee
status.

Regarding the method of payment, Ms. Havey was compensated by commissions
only and not a regular salary, which seems customary for sales work. The payments did
not withhold taxes or other deductions. However, “[t]he fact that a company did not deduct
Social Security or income taxes “is not a controlling factor in deciding whether an
employer-employee relationship existed.” Id. at *9. This factor favors neither party.

The next factor, the freedom to select and hire helpers, favors Ms. Havey as an
employee. Although the agreement permitted this, Ms. Havey testified that she knew of

6
no other New Bath Today sales representative who had helpers, and that during meetings,
New Bath Today never referred to anyone’s “team” but rather all sales representatives were
lone individuals. She conceded that possibly a seller exists who has helpers. But she also
pointed out the difficulty that any helper would encounter: an inability to access the
proprietary software that New Bath Today required for getting appointments and for
making sales presentations. New Bath Today offered no contrary evidence, including
proof of the existence of any “teams.” Thus, the Court agrees that this “right,” while
mentioned in the agreement, would be difficult to exercise.

As to the furnishing of tools and equipment, this factor favors neither. New Bath
Today provided the marketing materials, business cards, samples, and branded bags. It
also loaded Ms. Havey’s personal tablet computer with an app and software for use during
sales presentations. She used her personal phone for ascertaining her appointments and
communicating with other sales reps and her supervisors. Therefore, both parties furnished
the necessary tools to do the job, to varying extents.

As to self-scheduling of work hours, as previously mentioned, New Bath Today
required constant access to Ms. Havey between 8:00 a.m. to 4:00 p.m., four days per week.
She had no say in scheduling the appointments and had to be on standby when none were
available. New Bath Today stressed that it occasionally permitted her time off when she
requested it as proof of self-scheduling. However, Mr. Melton spoke of Ms. Havey’s
“luck” that her father died as the reason she was not terminated for taking an extended
break. Regardless, allowing this occasional time off (unpaid) pales in comparison to New
Bath Today’s constant scheduling demands and scrutiny during the time Ms. Havey did
work. This factor favors a finding of Ms. Havey as an employee.

Finally, regarding the freedom to offer services to other entities, Ms. Havey testified
that, given the full-time accessibility New Bath Today required, she had no opportunity to
do so. In Thompsen, the same held true: both parties agreed that the claimant was free to
offer his services to other companies, though the claimant testified that, as a practical
matter, the demands of his job made it impractical to work elsewhere. The Board held that
this statutory factor “tend[ed] to support a finding that the claimant was an independent
contractor.” Thompsen, 2015 TN Wrk. Comp. App. Bd. LEXIS 3 at *21. This factor
favors an independent contractor finding.

In sum, considering all seven factors, the last is the only one favoring New Bath
Today’s position. A couple of the factors are neutral. But most of the factors favor a
finding that Ms. Havey was an employee.

Therefore, the Court holds Ms. Havey met her burden. She is likely to prevail at a
hearing on the merits that she was New Bath Today’s employee and is entitled to benefits.

7
Benefits and Compliance Referrals

Tennessee Code Annotated section 50-6-204(a)(1)(A) states that an employer shall
furnish, free of charge to the employee, medical treatment made reasonably necessary by
the work-related accident. The statute further requires that an employer offer a panel of
three or more physicians, from which an employee may select one to evaluate and treat the
injury. § 50-6-204(a)(3)(A)(i). Given Ms. Havey’s testimony regarding the nature of her
alleged injuries, New Bath Today shall promptly provide her a panel of orthopedic
specialists.

Ms. Havey also requested temporary disability benefits. To receive temporary total
disability benefits, an employee must prove (1) total 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. Jones v. Crencor Leasing and Sales,
2015 TN Wrk. Comp. App. Bd. LEXIS 48, at *7 (Dec. 11, 2015).

Here, Ms. Havey did not introduce complete medical records to satisfy these
requirements, so her request for temporary disability benefits is denied at this time. She
may obtain this evidence and renew her request at a later expedited hearing or the
compensation hearing.

Along these lines, neither party offered a wage statement or other proof of Ms.
Havey’s earnings for the 52 weeks before her injury from which the Court could determine
her compensation rate.

New Bath Today is reminded that Tennessee Compilation Rules and Regulations
0800-02-21-.10(6) (2023) states, “Within seven (7) business days after the request of the
mediator or within fifteen (15) calendar days after a dispute certification notice is filed with
the clerk, the employer must provide a wage statement on a form approved by the
Administrator detailing the employee’s wages over the fifty-two (52) weeks before the
injury.” Because New Bath Today did not file a wage statement, the Court refers it to the
Compliance Program for investigation as to whether a penalty is appropriate.

Similarly, on this record, Ms. Havey filed her petition for benefit determination on
May 23, 2024, but New Bath Today did not deny the claim until July 16. Tennessee
Compilation Rules and Regulations 0800-02-14-.04(6) (2022) provides, “Decisions on
compensability shall be made by the adjusting entity within fifteen (15) calendar days of
the verbal or written notice of injury.” New Bath Today’s compensability decision was
untimely. The Compliance Program shall consider this for a potential penalty as well.

8
IT IS, THEREFORE, ORDERED AS FOLLOWS:

1. New Bath Today shall promptly offer a panel of orthopedic specialists for
evaluation and any reasonable and necessary treatment of Ms. Havey’s alleged
injuries from the March 6, 2023 fall.

2. New Bath Today shall file a wage statement within ten business days of entry of
this order.

3. Ms. Havey’s request for temporary disability benefits is denied currently.

4. A status hearing is set on July 28 at 10:00 a.m. Central Time. You must call (615)
532-9552 or (866) 943-0025 to participate.

5. 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
Insurer or Self-Insured 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. For questions regarding compliance, please contact the Workers’
Compensation Compliance Unit via email WCCompliance.Program@tn.gov.

ENTERED April 23, 2025.

________________________________________
JUDGE KENNETH M. SWITZER
Court of Workers’ Compensation Claims

9
APPENDIX

Exhibits:
1. Declaration of Julia Havey; no attachments except as listed below
2. Affidavit of Jason Bisch and attachments
3. MRI-Shoulder, July 29, 2024
4. Notice of Denial
5. Timeline (script-customized)
6. SageHome Sales Representative Agreement-Amended
7. Indeed job advertisement-Identification only
8. Screenshots, New Bath Today app
9. Text messages from Matthew Melton and Mike Rouser
10. Business card
11. Text messages from Matthew Melton
12. Letter from John Higgins to Ms. Havey and attachment
13. Group text messages
14. Email from adjuster to Ms. Havey
15. Payments from CC 1 US Holdings

CERTIFICATE OF SERVICE

I certify that a copy of this Order was sent as indicated on April 23, 2025.

Name Certified Regular Email Sent to
Mail mail
Julia Havey, X X juliagriggshavey@yahoo.com
employee 5560 Hwy 41A
Joelton TN 37080
Emily Pfeiffer, X Emily.Pfeiffer@Libertymutual.com
employer’s attorney Rachel.Dornier@Libertymutual.com
Compliance X WCCompliance.Program@tn.gov
Program

_______________________________________
Penny Shrum
Clerk, Court of Workers’ Compensation Claims
WC.CourtClerk@tn.gov

10
Right to Appeal:
If you disagree with the Court’s Order, you may appeal to the Workers’ Compensation
Appeals Board. To do so, you must:
1. Complete the enclosed form entitled “Notice of Appeal” and file it with the Clerk of the
Court of Workers’ Compensation Claims before the expiration of the deadline.
¾ If the order being appealed is “expedited” (also called “interlocutory”), or if the
order does not dispose of the case in its entirety, the notice of appeal must be filed
within seven (7) business days of the date the order was filed.
¾ If the order being appealed is a “Compensation Order,” or if it resolves all issues
in the case, the notice of appeal must be filed within thirty (30) calendar days of
the date the Compensation Order was filed.
When filing the Notice of Appeal, you must serve a copy on 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 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 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 your appeal.

3. You are responsible for ensuring a complete record is presented on appeal. If no court
reporter was present at the hearing, you may request from the Court Clerk the audio
recording of the hearing for a $25.00 fee. If you choose to submit a transcript as part of your
appeal, which the Appeals Board has emphasized is important for a meaningful review of
the case, a licensed court reporter must prepare the transcript, and you must file it with the
Court Clerk. The Court Clerk will prepare the record for submission to the Appeals Board,
and you will receive notice once it has been submitted. For deadlines related to the filing of
transcripts, statements of the evidence, and briefs on appeal, see the applicable rules on the
Bureau’s website at https://www.tn.gov/wcappealsboard. (Click the “Read Rules” button.)

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.
If neither party timely files an appeal with the Appeals Board, the Court Order
becomes enforceable. See Tenn. Code Ann. § 50-6-239(d)(3) (expedited/interlocutory
orders) and Tenn. Code Ann. § 50-6-239(c)(7) (compensation orders).

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;ĐŚĞĐŬŽŶĞŽƌŵŽƌĞĂƉƉůŝĐĂďůĞďŽdžĞƐĂŶĚŝŶĐůƵĚĞƚŚĞĚĂƚĞĨŝůĞͲ
ƐƚĂŵƉĞĚŽŶƚŚĞĨŝƌƐƚƉĂŐĞŽĨƚŚĞŽƌĚĞƌ;ƐͿďĞŝŶŐĂƉƉĞĂůĞĚͿ͗

□ 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 *

LB-1099 rev. 01/20 Page 1 of 2 RDA 11082
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

---

Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10850940. Public record. Not legal advice.