*The Form Must Be Original & Completed In Pen*
FORM I-5
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation 220 French Landing Drive Nashville, Tennessee 37243-1002
NOTICE OF WITHDRAWAL OF SOLE PROPRIETOR OR PARTNER ELECTION
I hereby notify the Tennessee Workers' Compensation Division that I, _______________________________________________________, being
Name
( ) sole proprietor ( ) Partner ( ) Member and engaged as such in the business of:
Business Name Federal Employer Identification Number (FEIN)
wish to withdraw my election to come under the provisions of the Tennessee Workers' Compensation Law. _________________________________________
Signature
_________________________________________
Social Security Number
_________________________________________
Business Address
_________________________________________
Business Address
Signed this ________________day of _________________________, 20_______.
LB-0287 (REV. 12/07)
RDA 10183