Free APPENDIX A - Tennessee


File Size: 18.1 kB
Pages: 1
File Format: PDF
State: Tennessee
Category: Workers Compensation
Author: cg04009
Word Count: 107 Words, 996 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.tn.us/labor-wfd/forms/i-5.pdf

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*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