Free APPENDIX A - Tennessee

*The Form Must Be Original & Completed In Pen*
FORM I-8

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

NOTICE OF ACCEPTANCE OF "WORKERS' COMPENSATION ACT" OF TENNESSEE BY EXEMPTED EMPLOYER Notice is hereby given that __________________________________________________________ FEIN _______________________ located at____________________________________________ elects to operate under the provisions of Chapter 9 through 12 of the Tennessee Code Annotated, officially designated "Workers' Compensation Act" of Tennessee, the said employer being otherwise exempt from the provisions of said Act, from the fact that: ___1. Less than 5 employees ___2. Domestic servants/farm or agricultural laborers ___3. City, county, or state government ___4. Other______________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ as provided by Section 50-6-106 of the Tennessee Code Annotated. The undersigned employer has insured his liability hereunder in the following manner-to-wit: ________________________________________________________________________________
Insurance Carrier name

________________________________________________________________________________
Street City State Zip In compliance with Section 50-6-405 of the Tennessee Code Annotated, which reads, in part, as follows:
Every employer under and affected by the workers' compensation law (1) shall insure and keep insured his liability hereunder in some person or persons, association, organization or corporation authorized to transact the business of workers' compensation insurance in this state; or (2) shall furnish to the commissioner of commerce and insurance satisfactory proof of his financial ability to pay all claims that may arise against such employer under this chapter and guarantee the payment of the same in the amount and manner and when due as provided for in this chapter. If the employer elects to pursue the latter course, the commissioner of commerce and insurance shall, without discretion, require the deposit of an acceptable security of indemnity bond to secure the payment of compensation liability as may be insured under such law. Said bond shall be conditioned to run directly for the benefit of the employees subject to the workers' compensation law, and may be enforced by them directly in an action in their name. This chapter shall not apply to policies of insurance against loss from explosion of boiler or fly wheels, or other similar single catastrophe hazards.

FEIN # : _____________________________________ Date signed ___________________________________ Business Name ________________________________ Type of Business ______________________________
(Manufacturer, Dealer, Etc.)

Signed by ____________________________________ Official ______________________________________
LB-0014 (REV. 12/07) RDA 10183