Free APPENDIX A - Tennessee

*The Form Must Be Original & Completed In Pen*
FORM I-4

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

ELECTION OF SOLE PROPRIETOR OR PARTNER TO COME WITHIN THE PROVISIONS OF THE TENNESSEE WORKERS' COMPENSATION LAW
FORM EFFECTIVE 30 DAYS AFTER TENNESSEE DEPARTMENT OF LABOR'S ACCEPTED STAMP DATE. ORIGINAL TO BE SENT TO THE DIVISION OF WORKERS' COMPENSATION WITH ALL PARTS FILLED OUT AND PROPERLY SWORN TO BEFORE NOTARY PUBLIC OR OTHER OFFICIAL.

To the Workers' Compensation Director: You are hereby notified that the undersigned Type or Print Name being a ( ) Sole proprietor ( ) Member ( ) Partner and being engaged as such in the occupation or business of:
Business name & Federal Employer Identification Number:

in the State of Tennessee, hereby elects to come under the provisions of the Tennessee Workers' Compensation Law. ____________________________________________
Signature

____________________________________________
Social Security Number

____________________________________________
Business Address: Street, City, State & Zip

Signed this ________day of ____________________, 20______.

Before me, the undersigned, a notary public in and for the county of __________________________________________ comes ___________________________, who is personally known to me to be the same person who executed the foregoing instrument of writing and such persons duly acknowledged the same to be his voluntary act and deed for the purposes of said writing herein set out. WITNESS my hand and my notary seal, this ______day of__________________, 20______. ________________________________ Notary Public Signature My Commission expires _____________________________________
LB-0228 (REV. 12/07) RDA 10183