Free APPENDIX A - Tennessee

*The Form Must Be Original & Completed In Pen*
FORM I-3

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Drive Nashville, Tennessee 37243-1002

NOTICE OF WITHDRAWAL FROM COVERAGE OF THE TENNESSEE WORKERS' COMPENSATION LAW

Business Name: _______________________________________________________________ Federal Employer Identification Number (FEIN):______________________________ Business Address: _____________________________________________________________ ____________________________________________________________________________ I hereby notify the Tennessee Workers' Compensation Division that my workforce has been reduced to less than five (5) persons and I no longer wish to remain subject to the Workers' Compensation Law. ________________________________________
Signature and Printed Name

________________________________________
Business Address

________________________________________
Business Address

Signed this _____________day of ________________,

20____.

LB-0286 (REV. 12/07)

RDA 10183