Free APPENDIX A - Tennessee

*The Form Must Be Original & Completed In Pen*
FORM I-6

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

NOTICE OF CORPORATE OFFICER TO EMPLOYER OF ELECTION NOT TO ACCEPT PROVISIONS OF "WORKERS' COMPENSATION ACT" OF TENNESSEE. INSTRUCTIONS: File an original, a photocopy of the completed original and a self-addressed stamped envelope (approved copy will be returned). The form must be complete, legible and notarized. If any information is missing, the form will be returned and will prolong the effective date until form is received complete. The effective date is 30 days after approved stamped date. Once approved the form is effective until withdrawn by the filing of a "FORM I-7 Notice of Corporate Officer's Revocation of Exemption" form. If the Business Name or corporate officers names or titles change a new form must be filed. Business Name ___________________________________________ Business Address
City State Zip

FEIN #_________________

Please furnish name and address of company or individual submitting this form. Name _________________________________Address _______________________________________________ You are hereby notified that the undersigned corporate officer elects not to be bound by the provisions of the Tennessee Workers' Compensation Act in compliance with section 50-6-104 of the said "Workers' Compensation Act" CORPORATE OFFICER REJECTING COVERAGE (PRINT) NAME___________________________________________________ CHECK TITLE:
President Secretary CEO COO V.P. Treasurer CFO

SIGNATURE_________________________________________SSN#:_______________________ Signed this ______________________day of ____________________________, 20_____________ Subscribed and sworn to before me this __________day of _____________,20________ Notary Public____________________________________________________________ My commission expires_______________________________________, 20__________ This is to certify that the above named corporate officer has served notice on his/her employer and said employer has not advised, counseled or encouraged the corporate officer to reject the provisions of the Workers Compensation Act , in compliance of section 50-6-104(b). Employer Signature_______________________________________________________________ ("Only" the "President" can sign as his/her own employer)

LB-0090 (REV. 12/07)

RDA 10183