Free APPENDIX A - Tennessee

*The Form Must Be Original & Completed In Pen*
FORM I-17 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Drive Nashville, Tennessee 37243-1002

NOTICE OF TERMINATION OF AGREEMENT OF GENERAL CONTRACTOR WITH SUBCONTRACTOR I hereby notify the Tennessee Workers' Compensation Division that I, (General Contractors Business Name and/or Sub-contractors Name General contractor insurance coverage with: General contractor _____________________________________________________
Generals Business Name

_______________ being a
& FEIN #)

Subcontractor wish to withdraw my agreement of workers' compensation

Subcontractor ________________________________________________________
Sub-contractors Individual Name

___________________________________________________
Signature of Sub-Contractor or General ____________________________________________________________ Social Security Number ____________________________________________________________ Business Address ____________________________________________________________ Business Address

Signed this _______________day of_______________, 20_______.

LB-0354 (REV. 12/07)

RDA 10183