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182
![Form LB-0489 "Separation Notice" - Tennessee](https://data.templateroller.com/pdf_docs_html/2089/20893/2089351/form-lb-0489-separation-notice-tennessee.png "Form LB-0489 "Separation Notice" - Tennessee")
Form LB-0489 "Separation Notice" - Tennessee
Size: 4 MB
3 pages
This a Tennessee document used to indicate information about a worker's employment termination, which will later be used to determine their qualification for unemployment compensation.
![Form SD-2 (LB-3261) "Statistical Data Form for Injuries on/After July 1, 2014" - Tennessee](https://data.templateroller.com/pdf_docs_html/2104/21046/2104654/form-sd-2-lb-3261-statistical-data-form-for-injuries-on-after-july-1-2014-tennessee.png "Form SD-2 (LB-3261) "Statistical Data Form for Injuries on/After July 1, 2014" - Tennessee")
![Form I-3 (LB-0286) "Notice of Reduction" - Tennessee](https://data.templateroller.com/pdf_docs_html/1904/19047/1904798/form-i-3-form-lb-0286-notice-of-reduction-tennessee.png "Form I-3 (LB-0286) "Notice of Reduction" - Tennessee")
![Form I-9 (LB-0289) "Notice of Withdrawal of an Exempt Employers' Voluntary Election" - Tennessee](https://data.templateroller.com/pdf_docs_html/1904/19047/1904799/form-i-9-form-lb-0289-notice-withdrawal-an-exempt-employers-voluntary-election-tennessee.png "Form I-9 (LB-0289) "Notice of Withdrawal of an Exempt Employers' Voluntary Election" - Tennessee")
![Form I-4 (LB-0228S) "Notice of Election" - Tennessee (English/Spanish)](https://data.templateroller.com/pdf_docs_html/2120/21203/2120305/form-i-4-lb-0228s-notice-of-election-tennessee-english-spanish.png "Form I-4 (LB-0228S) "Notice of Election" - Tennessee (English/Spanish)")
![Form TOSHA-7 "Report a Safety or Health Hazard Complaint Form" - Tennessee](https://data.templateroller.com/pdf_docs_html/2016/20164/2016424/form-tosha-7-report-a-safety-or-health-hazard-complaint-form-tennessee.png "Form TOSHA-7 "Report a Safety or Health Hazard Complaint Form" - Tennessee")
![Form C-33 (LB-0376) "Case Management Notification" - Tennessee](https://data.templateroller.com/pdf_docs_html/2426/24266/2426653/form-c-33-lb-0376-case-management-notification-tennessee.png "Form C-33 (LB-0376) "Case Management Notification" - Tennessee")
![Form C-20 (LB-0021) "Employer's First Report of Work Injury or Illness" - Tennessee](https://data.templateroller.com/pdf_docs_html/2438/24383/2438327/form-c-20-lb-0021-employer-s-first-report-of-work-injury-or-illness-tennessee.png "Form C-20 (LB-0021) "Employer's First Report of Work Injury or Illness" - Tennessee")
![Form C-42 (LB-0382) "Agreement Between Employer/Employee Choice of Physician" - Tennessee](https://data.templateroller.com/pdf_docs_html/2237/22377/2237761/form-c-42-lb-0382-agreement-between-employer-employee-choice-of-physician-tennessee.png "Form C-42 (LB-0382) "Agreement Between Employer/Employee Choice of Physician" - Tennessee")
![Formulario C-42 (LB-0382) "Agreement Between Employer/Employee Choice of Physician" - Tennessee (Spanish)](https://data.templateroller.com/pdf_docs_html/2314/23146/2314606/formulario-c-42-lb-0382-agreement-between-employer-employee-choice-of-physician-tennessee-spanish.png "Formulario C-42 (LB-0382) "Agreement Between Employer/Employee Choice of Physician" - Tennessee (Spanish)")
![Form C-40 (LB-0381) "Request for Mediation (For Injuries Prior to 7/1/2014 Only)" - Tennessee](https://data.templateroller.com/pdf_docs_html/2237/22377/2237764/form-c-40-lb-0381-request-for-mediation-for-injuries-prior-to-7-1-2014-only-tennessee.png "Form C-40 (LB-0381) "Request for Mediation (For Injuries Prior to 7/1/2014 Only)" - Tennessee")
![Form C-42 (LB-0382S) "Employee's Choice of Physician" - Tennessee (English/Spanish)](https://data.templateroller.com/pdf_docs_html/2068/20689/2068978/form-c-42-lb-0382s-employee-s-choice-of-physician-tennessee-english-spanish.png "Form C-42 (LB-0382S) "Employee's Choice of Physician" - Tennessee (English/Spanish)")
![Form C-26 (LB-0285) "Notice of Change or Termination of Compensation Benefits" - Tennessee](https://data.templateroller.com/pdf_docs_html/2120/21203/2120304/form-c-26-lb-0285-notice-of-change-or-termination-of-compensation-benefits-tennessee.png "Form C-26 (LB-0285) "Notice of Change or Termination of Compensation Benefits" - Tennessee")
![Form C-33 (LB-1023) "Case Management Notification" - Tennessee](https://data.templateroller.com/pdf_docs_html/2068/20689/2068977/form-c-33-lb-1023-case-management-notification-tennessee.png "Form C-33 (LB-1023) "Case Management Notification" - Tennessee")
![Form C-31 (LB-0379S) "Medical Waiver and Consent" - Tennessee (English/Spanish)](https://data.templateroller.com/pdf_docs_html/1904/19047/1904765/form-c-31-form-lb-0379s-medical-waiver-and-consent-tennessee-english-spanish.png "Form C-31 (LB-0379S) "Medical Waiver and Consent" - Tennessee (English/Spanish)")
![Form C-39 (LB-0968) "Application for Registration for Utilization Review Organization" - Tennessee](https://data.templateroller.com/pdf_docs_html/1904/19047/1904766/form-c-39-form-lb-0968-application-registration-utilization-review-organization-tennessee.png "Form C-39 (LB-0968) "Application for Registration for Utilization Review Organization" - Tennessee")
![Form C-47 (LB-1017) "Medical Payment Committee Review Request" - Tennessee](https://data.templateroller.com/pdf_docs_html/1904/19047/1904767/form-c-47-form-lb-1017-medical-payment-committee-review-request-tennessee.png "Form C-47 (LB-1017) "Medical Payment Committee Review Request" - Tennessee")
![Form I-13 (LB-0290) "Notice of Withdrawal of a Previously Signed Waiver" - Tennessee](https://data.templateroller.com/pdf_docs_html/1904/19048/1904801/form-i-13-form-lb-0290-notice-withdrawal-a-previously-signed-waiver-tennessee.png "Form I-13 (LB-0290) "Notice of Withdrawal of a Previously Signed Waiver" - Tennessee")
![Form I-15 (I-17; LB-0301) "General Contractor Acceptance/Termination of Coverage Agreement" - Tennessee](https://data.templateroller.com/pdf_docs_html/1904/19048/1904802/form-i-15-i-17-lb-0301-general-contractor-acceptance-termination-of-coverage-agreement-tennessee.png "Form I-15 (I-17; LB-0301) "General Contractor Acceptance/Termination of Coverage Agreement" - Tennessee")
![Form C-22 (LB-0024) "Notice of First Payment of Compensation" - Tennessee](https://data.templateroller.com/pdf_docs_html/1905/19054/1905404/form-c-22-lb-0024-notice-of-first-payment-of-compensation-tennessee.png "Form C-22 (LB-0024) "Notice of First Payment of Compensation" - Tennessee")
![Form C-36 (C-37; LB-0375) "Utilization Review Closure" - Tennessee](https://data.templateroller.com/pdf_docs_html/568/5682/568281/form-c-36-c-37-lb-0375-utilization-review-closure-tennessee.png "Form C-36 (C-37; LB-0375) "Utilization Review Closure" - Tennessee")
![Form C-43 (LB-0988) "Permanent Total Disability Final Order" - Tennessee](https://data.templateroller.com/pdf_docs_html/1904/19047/1904794/form-c-43-form-lb-0988-permanent-total-disability-final-order-tennessee.png "Form C-43 (LB-0988) "Permanent Total Disability Final Order" - Tennessee")
![Form LB-385 "Request to Resume Mediation" - Tennessee (English/Spanish)](https://data.templateroller.com/pdf_docs_html/2438/24383/2438333/form-lb-385-request-to-resume-mediation-tennessee-english-spanish.png "Form LB-385 "Request to Resume Mediation" - Tennessee (English/Spanish)")
![Form LB-385 "Request to Resume Mediation" - Tennessee](https://data.templateroller.com/pdf_docs_html/2438/24383/2438332/form-lb-385-request-to-resume-mediation-tennessee.png "Form LB-385 "Request to Resume Mediation" - Tennessee")
![Form C-35A (LB-1023) "Notice of Appeal Rights for a Utilization Review Denial" - Tennessee](https://data.templateroller.com/pdf_docs_html/2470/24706/2470684/form-c-35a-lb-1023-notice-of-appeal-rights-for-a-utilization-review-denial-tennessee.png "Form C-35A (LB-1023) "Notice of Appeal Rights for a Utilization Review Denial" - Tennessee")
![Form RSA (LB-0932) "Request for Settlement Approval" - Tennessee](https://data.templateroller.com/pdf_docs_html/2237/22377/2237766/form-rsa-lb-0932-request-for-settlement-approval-tennessee.png "Form RSA (LB-0932) "Request for Settlement Approval" - Tennessee")
![Form C-42G "Employee's Choice of Physician" - Tennessee](https://data.templateroller.com/pdf_docs_html/243/2432/243244/form-c-42g-employee-s-choice-physician-tennessee.png "Form C-42G "Employee's Choice of Physician" - Tennessee")
![Form LB-0441 "Report to Determine Status - Application for Employer Number" - Tennessee](https://data.templateroller.com/pdf_docs_html/2518/25186/2518639/form-lb-0441-report-to-determine-status-application-for-employer-number-tennessee.png "Form LB-0441 "Report to Determine Status - Application for Employer Number" - Tennessee")
![Form LB-0355 "Child Labor Parental Statement of Consent" - Tennessee](https://data.templateroller.com/pdf_docs_html/2438/24383/2438329/form-lb-0355-child-labor-parental-statement-of-consent-tennessee.png "Form LB-0355 "Child Labor Parental Statement of Consent" - Tennessee")
![Form LB-3304 "Request for Investigation" - Tennessee](https://data.templateroller.com/pdf_docs_html/2438/24383/2438330/form-lb-3304-request-for-investigation-tennessee.png "Form LB-3304 "Request for Investigation" - Tennessee")
![Form LB-3304 "Request for Investigation" - Tennessee (English/Spanish)](https://data.templateroller.com/pdf_docs_html/2438/24383/2438331/form-lb-3304-request-for-investigation-tennessee-english-spanish.png "Form LB-3304 "Request for Investigation" - Tennessee (English/Spanish)")
![Form LB-1111 "Drug Free Workplace Program Application" - Tennessee (English/Spanish)](https://data.templateroller.com/pdf_docs_html/2438/24383/2438326/form-lb-1111-drug-free-workplace-program-application-tennessee-english-spanish.png "Form LB-1111 "Drug Free Workplace Program Application" - Tennessee (English/Spanish)")
Form LB-1111 "Drug Free Workplace Program Application" - Tennessee (English/Spanish)
Size: 267 KB
2 pages
![Form LB928A "Physician Application for Appointment to the Certified Physician Program (Cpp) and/or Medical Impairment Rating (Mir) Registries" - Tennessee](https://data.templateroller.com/pdf_docs_html/2518/25186/2518637/form-lb928a-physician-application-for-appointment-to-the-certified-physician-program-cpp-and-or-medical-impairment-rating-mir-registries-tennessee.png "Form LB928A "Physician Application for Appointment to the Certified Physician Program (Cpp) and/or Medical Impairment Rating (Mir) Registries" - Tennessee")
![Form LB-3298 "Application for Amusement Device Operating Permit" - Tennessee](https://data.templateroller.com/pdf_docs_html/2438/24383/2438325/form-lb-3298-application-for-amusement-device-operating-permit-tennessee.png "Form LB-3298 "Application for Amusement Device Operating Permit" - Tennessee")
![Form LB-1111 "Drug Free Workplace Program Application" - Tennessee](https://data.templateroller.com/pdf_docs_html/2237/22377/2237765/form-lb-1111-drug-free-workplace-program-application-tennessee.png "Form LB-1111 "Drug Free Workplace Program Application" - Tennessee")
![Form LB-0386 "Application for License to Engage in the Erection, Repair, and/or Alteration of Boilers and Pressure Vessels in the State of Tennessee" - Tennessee](https://data.templateroller.com/pdf_docs_html/2238/22381/2238121/form-lb-0386-application-for-license-to-engage-in-the-erection-repair-and-or-alteration-of-boilers-and-pressure-vessels-in-the-state-of-tennessee-tennessee.png "Form LB-0386 "Application for License to Engage in the Erection, Repair, and/or Alteration of Boilers and Pressure Vessels in the State of Tennessee" - Tennessee")
![Form LB1095 "Petition for Benefit Determination" - Tennessee (English/Spanish)](https://data.templateroller.com/pdf_docs_html/2237/22377/2237767/form-lb1095-petition-for-benefit-determination-tennessee-english-spanish.png "Form LB1095 "Petition for Benefit Determination" - Tennessee (English/Spanish)")
![Form LB-1098 "Hearing Request" - Tennessee](https://data.templateroller.com/pdf_docs_html/2213/22131/2213159/form-lb-1098-hearing-request-tennessee.png "Form LB-1098 "Hearing Request" - Tennessee")
![Form LB1120 "Petition for Benefit Determination - Settlement Approval Only" - Tennessee](https://data.templateroller.com/pdf_docs_html/2213/22131/2213160/form-lb1120-petition-for-benefit-determination-settlement-approval-only-tennessee.png "Form LB1120 "Petition for Benefit Determination - Settlement Approval Only" - Tennessee")
![Form LB-0441 "Report to Determine Status Application for Employer Number" - Tennessee](https://data.templateroller.com/pdf_docs_html/2213/22135/2213505/form-lb-0441-report-to-determine-status-application-for-employer-number-tennessee.png "Form LB-0441 "Report to Determine Status Application for Employer Number" - Tennessee")