Free APPENDIX A - Tennessee

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FORM I-7 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Drive Nashville, Tennessee 37243-1002

NOTICE OF CORPORATE OFFICER'S REVOCATION OF EXEMPTION

I hereby notify the Tennessee Workers' Compensation Division that I, __________________________________________________, being a corporate
Name

Officer, employed by __________________________________________________________
Business Name and FEIN #

___________________________________________________________________________
Street City State Zip

wish to withdraw my election to be exempt from the Tennessee Workers' Compensation Law.

__________________________________________________
Signature ____________________________________________________________ Social Security Number ____________________________________________________________ Business Address ____________________________________________________________ Business Address

Dated this ______________day of ______________, 20_________.

LB-0288 (REV. 12/07)

RDA 10183